MII Member Assessment Application Form

Note: To attend for MII Member assessment you must be a registered Associate Affiliate

Name (please print):

Address:

Tel:Mobile:

Email1:

1All MII communications are by email (except for election materials). The onus is on the member to ensure that the MII has their correct current email address.

Please Indicate Area of Practice:

Please tick the appropriate box(s) and/or specify other area of practice:

Agriculture □ Civil and Commercial □ Community □ Construction □ Elder Mediation □ Environment □

*Family □ Healthcare □ Insurance □ Organisational/Workplace □ Professional Negligence □ Restorative Justice □ Separating Couples □ Other (please specify):

*Family denotes interfamily disputes (e.g. sibling; parent/adult child etc.) other than separating couples.

Please ensure that the following are included with your assessment form:

Assessment fee of €275.00/St£230.00□

Completed Member Assessment Application Form□

Note: Fee may be paid in either Euro or Sterling.

Please indicate preferred dates for Assessment:

Note:

Assessments will be held in Dublin and are open to registered MII Associate Affliates.
Places will be allocated on a first-come, first-served basis.
Please refer to the MII website for full details of the assessment process:
The MII will notify applicants as soon as possible in the unlikely event of a change to dates for Member status assessments.

Signed:

Payment options;

·Cheque payable to the MII sent to The Mediators’ Institute of Ireland, Unit 2.1, The Distillers Building, Smithfield, Dublin 7

· Bank Transfer

Payments in Euro

IBAN: IE97 AIBK 9310 4717 4580 69 BIC: AIBKIE2D

When making a transfer please be sure to use your name as a reference so that the payment can be identified when it arrives.

Payments in Sterling

IBAN: GB65 AIBK 2385 9012 4900 43 BIC: AIBKIE2D

· Paypal to

The Mediators’ Institute of Ireland Unit 2.1 The Distillers Building Smithfield Dublin 7

T: 353 1 609 9190 •E: • W: