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Home My WebLink AboutInv# 19691=CFRA - State of Florida - 10/20/2021Application for Mediator Certification Renewal Florida Dispute Resolution Center-Supreme Court Building-500 South Duval Street~ Tallahassee, Florida-32399 DRCmail@flcourts.org ~Phone 850.921.2910 ~Fax 850.922.9290 Certification Number Re uired 19691 CFRA Renewal Date Re uired 1/27/2022 Visit the link below to look up your Certification Number and Renewal Date Mediator Search Certification Type (Check All That Apply): Administrative Use Only F N Q CME IE1 County (C) IE1 Family (F) IE1 Circuit (R) □ Dependency (D) IE1 Appellate (A) Full Name (as on file with DRC)I ... L_in_d_a_s_. _G_o_n_z_a_le_z _______________ _ Primary Mailing Address* Street r811 Montevideo Avenue City lcooper City ] Zip Code 133026 Secondary Mailing Address Street 1100 W. Dania Beach Blvd. Zip Code 133004 County State Florida Country lunited States[3 City loania Beach County (Broward a Primary Contact Phone Numbers l3os.8o7.8689 11 ___________ ..... 1 I 1_1 __ J I I 1 ___ 1 Email Address IU ndagonza lezcmb@hotmai I State 1Florida(3 Country lunited States (If a P.O. Box is your primary, you must have a physical address as your secondary address) *Your primary address will be listed on the Mediator Search webpage unless you check this box D Renewal Fees** C, F, R & A $415.00 Make your check or money order payable to State of Florida **NOTE: For certifications that have lapsed 1-180 days, renewal fees are double the amounts listed; certifications that have lapsed 181-365 days are five times the amounts listed up to a maximum of $750. An application for mediator renewal will not be processed without the correct fees. Page 1 of 3 Good Moral Conduct Please be advised that all renewals will be the subject of a background check. Please answer each question below. a. Have you ever been convicted of, pied guilty, or pied no contest, rega~dless C?f whet~er adjudication of guilt or imposition of sentence was suspended, deferred, or withheld in relation to any of the following: (1) (2) (3) (4) a felony, misdemeanor of the first degree, or misdemeanor of the second degree involving dishonesty or false statement; a conviction of a similar offense described in subdivision (1) that includes a conviction by a federal, military, or tribal tribunal, including courts-martial conducted by the Armed Forces of the United States; a conviction of a similar offense described in subdivision (1) that includes a conviction or entry of a plea of guilty or no contest resulting in a sanction in any jurisdiction of the United States or any foreign jurisdiction. A sanction includes, but is not limited to, a fine, incarceration in a state prison, federal prison, private correctional facility, or local detention facility; or a conviction of a similar offense described in subdivision (1) of a municipal or county ordinance in this or any other state. INo [51 b. Have you ever been sanctioned for a breach of ethics or unprofessional conduct by any & ~ ... : court, administrative agency, bar association or other professional group? (Note: if no probable .... LN_o __ ... ~ •.. 1111 cause was found, there is no need to report). c. Within the last five years, have you ever been demoted, disciplined, suspended, terminated or formally reprimanded by an employer because of immoral conduct, substance I □ abuse, sexual impropriety or abusive behavior? If so, please state the circumstances under No □ which such action was taken, the date(s) such action was taken, the name(s) of any persons ____ .., who took such action, the background and resolution of such action and relevant documentation. d. Have you ever applied for certification or licensure in any state as a member of a recognized INo □ profession and been denied? ,_ ____ [3 ... ~ ... : e. Have you ever had a final judgment for protection against domestic violence, dating violence or INo t;1 stalking entered against you? t.:J ----- f. Has the incident(s) noted above been previously reported on a mediator certification application ...---.._111111 or renewal? If so, please provide the date of the application or renewal and the MQB or QCC case INo r;I number. You do not need to provide any documentation previously submitted. .... ___ __.!11.1t;1111 Date I ~-----~ Case Number! ..... ______ ___, If you answered yes to any of the above, you must provide the following information a) Copies of all documentation related to the case; b) A statement, sworn to be truthful, as to the circumstances surrounding the incident(s); c) A statement describing and a copy of the order if currently on probation; d) Any effort at rehabilitation; and e) Any other information you believe would be useful in reviewing your application. Page 2 of 3 Sworn Statement 1, l..,od-c, 6or12.-4{., L . swear and affirm all of the following: that the information supplied on this application is correct, and that to the best of my knowledge, I qualify for the certification(s) for which I have applied. I will notify the Dispute Resolution Center (DRC), in writing, of any material change in circumstance or condition stated in the application which takes place between the initial filing of the application and the final granting or denial of certification. I understand that any omissions, falsifications, misstatements or misrepresentations of the information provided in this application, or information required to be subsequently provided, may disqualify me for certification and, if I am certified, may be grounds for discipline including decertification. Signature of Applicant Dated lo /;;..o hr, ----.......z.,+.z:....---t,--:::,,.1--------------------------- NOTE: If you answer yes to any of the background questions and do not provide all copies of related information, you will be asked to furnish additional documents and sworn statements before your application will be reviewed. Page 3 of 3 Single Certification County (C) Family (F) Circuit (R) Dependency (D) Appellate (A) Dual Certifications C&R C &F C&D F&R F &D F&A R&A D&A Three Certifications C, F & R C, F & D C, R, & D C, F, &A C, R,&A C, D&A F, D &R F, R&A F, D&A R, D&A Mediator Renewal Fees -AOSC11-1 Including Multi Certification Combinations $40.00* $150.00 $150.00 $100.00 Renewed with F, R or D $190.00 $190.00 $140.00 $275.00 $225.00 $225.00 $225.00 $175.00 $315.00 $265.00 $265.00 $265.00 $265.00 $215.00 $375.00 $375.00 $325.00 $325.00 Four Certifications C, F, D &R C, F, R &A C, F, D &A C, R, D &A F, D, R, &A All Five Certifications C, F, D, R, & A $415.00 $415.00 $365.00 $365.00 $450.00 $490.00 Note: For certifications that have lapsed 1-180 days, renewal fees are double the amounts listed; certifications that have lapsed 181-365 days are five times the amounts listed up to a maximum of $750. Name [unda Gonzalez Continuing Mediator Education (CME) Reporting Form Renewal Date ._[,_12_1_12_0_22 ______________ _ Generally: Sixteen hours of CME, which shall include a minimum of four hours of mediator ethics, a minimum of two hours of interpersonal violence education, and a minimum of one hour of diversity/cultural awareness education in each two year renewal cycle. All_certified mediators must_~QnJ..Q.le.te_a minimum of eighthours in a live~ormat Family and Dependency: Family and Dependency mediators must complete an additional two hours of interpersonal violence (IPV) education for a total of four hours. Appellate: Appellate mediators automatically fulfill their CME requirement by reporting 16 hours in their family, circuit, or dependency certifications. Date CME Program Title & Education Method: Earned Sponsoring Organization Live or Non-Live It is the mediator's responsibility to keep track of CME hours and report their CME hours at the end of each two-year renewal cycle. The mediator shall be responsible to keep all records relating to CME and shall be subject to audit. Please retain your documentation and send it only if you are notified of an audit. C 0 u n t y ~uly, 16, 2020 dvanced Mediation Training Wrkshop -C ILive ~1 c--: ■18 118 F a m y C I r C u i T e E I i p t p V e h e n V r d i s e C n s C y anuary 13, 2021 dvanced Med;a,;on na;n;ng Wo,kshop -luve ~ ~ ~ ~ ~ I f ~ r I.----··· -I ~C 1111111 I ,----1 ~11111111 I I ~r--• 1111111 I ~--1 Glr--1111111 II ~11111111 Signature ____ -F-~<----------Total CME Hours [~----F]·-V i--[-r. ~-Date /1J1/4.-d/lt ,_; %1•• •••,,; ••x• > W•H O O•' , , ;::,_,.7;•7; ...•. *'i:i ,,,.-~·/f-., ·.~: .. ~.!''.di 'F~~' ❖ ,; '\'' ,',,,, P·&iLj'@i®W '' ~ ,. ·,,/:~/<·'~; Mediation Training Group, Inc. Certificate of Attendance Linda Gonzalez Advanced Mediation Training Workshop Program-A January 13, 2021 _8_ Hours of Continuing Mediator Education (CME) including _4_ Hours of Ethics, _1_ Hours of Diversity _2_ Hours of Interpersonal Violence _1_ Hour(s) of General Mediation 'Rooi,v\,s Ccwcw Shcvw, faq Primary Trainer Chcu-l.e-tw, St"curtporev Admin Mediation Training Group, Inc. Certificate of Attendance Linda Gonzalez Advanced Mediation Training Workshop Program-C July 16, 2020 _8_ Hours of Continuing Mediator Education (CME) including _4_ Hours of Ethics, _l_ Hours of Diversity _2_ Hours of Interpersonal Violence _ l _ Hour( s) of General Mediation 'Robi-rt,, Ccurcw SMMI, E~ Primary Trainer COUNTY: CME Requirements for Florida Supreme Court Certified County, Family, Circuit, Dependency and Appellate Mediators 16 hours of which must include at least: 4 hours of Mediator Ethics, 2 hours of Interpersonal Violence Education 1 hour of Diversity /Cultural Awareness. CIRCUIT: 16 hours of which must include at least: 4 hours of Mediator Ethics, 2 hours of Interpersonal Violence Education 1 hour of Diversity/Cultural Awareness. FAMILY: 16 hours of which must include at least: 4 hours of Mediator Ethics, 4 hours of Interpersonal Violence Education 1 hour of Diversity/Cultural Awareness. DEPENDENCY: 16 hours of which must include at least: 4 hours of Mediator Ethics, 4 hours of Interpersonal Violence Education 1 hour of Diversity/Cultural Awareness. APPELLATE: Appellate mediators automatically fulfill their CME requirements by reporting 16 hours in their Family, Circuit, or Dependency certifications NOTE: Mediators who are certified in more than one area must complete sixteen hours of CME applicable to each of their areas of certification. Hours completed may be utilized toward more than one area of certification if the subject matter is relevant to each field of certification. For example, courses on such topics as mediator ethics, interpersonal violence, and general mediation skills may be credited to any or all of the areas of certification. For more information on Mediator CME refer to AOSC19:26 Information for Completing the CME Reporting Form Date CME Earned -Place the date you completed the CME hours in this column. Program Title & Sponsoring Organization -Place the name of the program as well as the organization providing the CME. For mentoring, provide the name of the person you mentored. for publications, provide the title of the article and the name of the publication. Education Method -Indicate if the CME was completed via a live or non-live method as shown below. live Methods • attendance at a live lecture or seminar; • attendance at an audio/video playback of a seminar attended by no less than two persons who discuss the materials presented after the conclusion of the playback; • attendance at an interactive internet presentation that includes audience participation in real time; • participation as a lecturer, presenter, or panel member in a CME program; • serving as a mentor under rule 10.100, Rorida Rules for Certified and Court-Appointed Mediators (4 hours maximum); or • attendance at court alternative dispute resolution committee and board meetings for time spent on mediation topics. Non-live Methods • listening to or viewing previously recorded presentations alone; • attendance at a web-based seminar without real time audience participation; • authoring or editing written materials submitted for publication; or • successfully completing a self-directed program that is qualified for continuing education credit by a governmental licensing board. Total Hours -The total number of real time hours of the program, based on a 50-minute hour, should be noted in this column. Number of Applicable Hours -Record all applicable hours under the appropriate column. Applicable hours will exceed the total number of real hours if components of mediator ethics, diversity and IPV are induded. for example, a county mediator who completed a four-hour county CME program that contained two hours of ethics and one hour of diversity would record four hours under county, two hours under mediator ethics and one under diversity. Mediator Ethics -We recognize ethics are important in all professions; therefore, other professional ethics can be used toward general CME, but cannot replace the four hours of mediator ethics. Interpersonal Violence (IPV) Education -Any type of IPV education meets this requirement and does not need to be mediation specific. Diversity/Cultural Awareness -Any type of diversity education meets this requirement and does not need to be mediation specific. Please make additional copies of the CME Form as necessary. You must also sign and date each individual page you are submitting. The purpose of continuing mediator edtJCation (CME) shall be to enhance the participant's professional competence iJS a mediator. These requirements apply to all certified mediators seeking renewal. Certification shall not be renewed untU all CME requirements are completed. Definition To qualify as CME, a course or activity shall have significant, current intellectual or practical content and shall constitute an organized program of learning directly related to the practice of mediation. CME shall be conducted by an individual or group qualified by practical or academic experience. Mediators who are certified in more than one area must complete 16 hours of CME applicable to each of their areas of certification. Hours completed may be utilized toward more than one area of certification if the subject matter is relevant to the field(s) of certification. For example, courses on mediator ethics, interpersonal violence education, diversity and general mediation skills may be credited to all areas of certification. Reporting Requirements Mediators must maintain proof of attendance of CME or other appropriate documentation and must report their CME at the end of each two-year renewal cycle on the Center's renewal form. The mediator shall be responsible to keep all records relating to CME and shall be subject to audit. Any CME hours completed may be utilized for only one renewal cycle. Hours in excess of the requirement shall not be carried forward to the next renewal cycle. If all other qualifications for renewal are met, but a review reveals a deficiency in CME credits, the mediator shall be notified in writing and certification shall be continued for 90 days from the notice of non-compliance. During those 90 days, the mediator shall complete all remaining CME requirements in order to be eligible for renewal. Material Misrepresentation Any misrepresentation shall be automatically referred to the Mediator Qualifications and Discipline Review Board. Florida Dispute Resolution Center Supreme Court Building 500 S. Duval Street Tallahassee, FL 32399 (850) 921-2910 Email: DRCmail@flcourts.org