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					                                                     Registration Form
                                         NATIONAL ASSOCIATION OF REALTORS
                                                 Mediator/Mediation Training
                        (available at

The June 27, 28, and 29, 2012 seminar will be held at the NATIONAL ASSOCIATION OF REALTORS building in
Chicago, 430 N. Michigan Avenue, on the second floor.

Attendees must participate in all scheduled sessions. Although prior training and/or experience in mediating real estate
related disputes is helpful, it is not necessary to have prior training/experience to attend. All are welcome. Please
complete the enclosed attendee profile.

Attendees (or their sponsoring organizations) are responsible for their transportation, lodging, meals (other than those
provided by NAR), and incidental costs.

Reservations must be made directly with the Courtyard by Marriott Magnificent Mile by calling 312-573-0800 or
800-321-2211. Please reference “NAR’s Mediation Meeting” to take advantage of the $169 per night room rate.

Only the first fifty (50) registrations that are received will be accepted.

Information provided immediately below used for attendee roster and to contact you regarding the program.
                                            (Please print or type)

Name:                                                                       Nickname (optional):


City:                                                          State:                              Zip:

Telephone:                                                           Fax:


Board or Association:

Please attach to your registration form a description of any disability requiring special services at this seminar.

Completed registration forms must be accompanied by an attendee profile to optimize attendees’ learning experience,
and can be sent to the Member Policy Department, NATIONAL ASSOCIATION OF REALTORS , 430 North Michigan
Avenue, Chicago, Illinois 60611 (e-mail or fax to Bernice Barajas in the Member Policy
Department at 312-254-3188).

Registration fee is $150 (nonrefundable after June 1).

    check enclosed, make payable to:
    NATIONAL ASSOCIATION OF REALTORS®, account # 01-358-321

   credit card payment:
   Visa          MasterCard             American Express                 Diners Club

Credit Card #                                                                          Exp. Date

Cardholder NRDS ID# (required)                                                Signature

Cardholder name and billing address (required)
                                                   Attendee Profile
                                        NATIONAL ASSOCIATION OF REALTORS
                                                Mediator/Mediation Training
                       (available at

To optimize attendee’s learning experience, this form must be submitted with the registration form. Although prior
formal training in mediation and/or practical experience in mediating disputes between REALTORS  is helpful, prior
training/experience is not required. All individuals affiliated with the REALTOR family are welcome to attend.

Attendee information


Board or Association

State Association

    Number of years as a broker                Number of years as a sales licensee

    Number of years as an association executive or staff specialist

    Other, please explain

    Professional designations

Professional standards experience (approximate)

Local Grievance Committee           # years                Local Professional Standards Committee       # years

State Grievance Committee           # years                State Professional Standards Committee       # years

Local Board of Directors service    # years                NAR Professional Standards Committee         # years

State Board of Directors service    # years                Mediation officer                            # years

Staff                               # years                Mediations conducted (how many)                    #

Mediation skills
Formal training as a mediator

Year         Training provided by                                                               Hours of instruction

                                                         Page 1
Practical (“on the job”) training as a mediator, including dates. Attach additional pages if necessary.

Summarize experience as a mediator conducting mediations over the past three (3) years. Attach additional pages if

Please describe your primary mediation style (e.g., facilitative, evaluative, other).

Other relevant training or experience.

Training experience
Experience in personally conducting mediator training, if any, over the past three (3) years. Please describe training.
Attach additional pages if necessary.

Briefly describe training programs (other than mediation training) that you have personally conducted over the past three
(3) years. Attach additional pages if necessary.

Please list any specific topics or issues you would like to see addressed in this seminar.

Important note: A completed attendee profile must accompany the registration form. Thank you.

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