Full Name (Accredited Mediator): *
Name of Practice:For invoicing purposes
Race *— Select —BlackWhiteIndianColoured
ID Number: *
Gender: *— Select —MaleFemale
Email Address: *
Mobile Number: *
Address *
City: *
Region: * Gauteng Mpumalanga Limpopo Kwa-Zulu Natal Eastern Cape Northern Cape Western Cape North West Free State
Website Address:http://www.domainname.co.za
Mediation Type: * In Person Online Both In Person & Online
Upload Profile Photo
Profession: *Are you an attorney, Dr, Engineer etc
Professional registration authority: *EG: Law Society, HPCSA, etc
Professional Registration Number:
Mediation Specialty: * Family Labour Financial (Credit-Banking-Insolvency-Insurance etc) Commercial Medical (RAF Personal Injury-Malpractice-etc) Construction Property Insolvency & Business Rescue Intellectual Property Mining & Metallurgy Taxation & Exchange Control Technology, Media & Telecommunications
Other:Please list Specialty
Have you completed the required Training? Yes No
Mediation Training Provider: *
Training Certificate: *
Max 2 documents, 3 MB each. At least 1 document required; additional documents are optional.
Able to function as: * Sole Mediator Co-Mediator Observer Mediator
Years Accredited as a Mediator: *— Select —1-56-1010-1515+
Number of completed Mediations: *— Select —0-1011-5051-100100+Number of completed Mediations
Years of Experience in RAF/Medico-legal matters: *— Select —None1-55-1010+How many matters can you handle per month?
Letter of Experience:
Max 2 documents, 3 MB each.
Years of Experience in any medical matters: *— Select —0-23-55-1010+
Monthly Mediation Capacity: *How many matters can you handle per month?
Language: *— Select —EnglishAfrikaansZuluXhosaOther
Other languages:
Mediation Agreement:
Fee Per Hour - Excl VAT:
I confirm that I have read, understood, and agree to comply with the TSWELEPELE ADR policies and frameworks linked below, including the Mediator Code of Conduct and Disciplinary Framework.
Panelist Agreement
Code of Professional Conduct
Disciplinary Policy
I accept the Tswelopele ADR Policies and agreements *
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