Community Mediation Service Provider Sign Up

1. Personal Details

Gender MaleFemaleOther

First name:

Surname:

Organisation (if applicable):

Address:

Street:

Town:

County:

Postal code:

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2. Contact Details

Mobile:

Phone/Landline:

Company:

Website:

Email:

Create Password:(Please include one or more upper and lower case letters, numbers, and marks)

Confirm Password:

Corporate Code (optional):

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4. Profile Details

Please upload the following (it is optional to upload files, this can be skipped):

Profile image.
Please supply a copy of your certificate for completing your MII accredited training.
Please supply a copy of the last page of your MII Assessor’s Report (must be dated within the past year).
If you have difficulty uploading your files you may email them to info@themii.ie to request they be added to your application.

Allowed file types for upload: doc, docx, pdf, xls, xlsx, jpeg, gif, png

Max file size: 1.2MB

Upload Profile Image

Upload Certificate

Upload MII Assessor’s Report

Declarations:

Have you ever been convicted of a relevant criminal offence? YesNo

Have you ever been subject to any sanction, including reprimand, suspension or expulsion, by or from any professional or regulatory body in any country? YesNo

Have you ever been refused admission or Registration by any professional or regulatory body in any country? YesNo

Are there at present any proceedings under way which might affect your status in respect of any of these. YesNo

If you have answered "Yes" to any of these questions please supply details:

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5. Summary

Terms and Conditions:

I have read and agree to abide by the MII Code of Ethics and Practice I have read and agree to abide by the MII Code of Ethics and Practice I agree to be bound by the MII Complaints and Disciplinary Procedure I agree to be bound by the MII Complaints and Disciplinary Procedure I have appropriate insurance in place for my mediation practice (if applicable) I have appropriate insurance in place for my mediation practice

Not yet insured - comment on reason why:

Payment Offline:Online with Paypal, Debit or Credit Card:

Community Mediation Service Provider Form

To complete this application form you will require the following information: