Membership Step 1 of 3 - Section A 0% Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Gender*MaleFemaleAge*Please enter a number from 18 to 90.Mobile*Email* Enter Email Confirm Email Address* Physical Address Postal Address AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Date of which you qualified as a certified mediator* Training programme/s you attended.*Your profession/Occupation.*Category of membership*StudentAssociateFellow charteredMembership to professional bodies*Please Indicate Area(s) of Practice as a mediatorCivil and CommercialCommunityConstructionEnvironmentFamilyInsuranceHealthcareOrganisational/WorkplaceProfessional NegligenceRestorative JusticeOther (please specify) Date for AssessmentPlease submit your form and we will revert to you with a proposed date of assessment.Checklist for submission of applicationPlease note, all the requirements below must be fulfilled before progressing to interview for admission into membership of ICMC.Untitled*Copies of Your academic and professional certificatesCase Overviews: An outline of the 3 cases which you believe showcase your Professional Mediator skills max one page (parties names should be avoided for confidentiality )Personal Statement and Reflective Practice StatementAny other work you have done to promote mediation since you were certified.A letter of confirmation from the institution that trained youFilesNote1. The form must be accompanied with 1000Kshs non-refundable fee and a copy of pay in slip. Payable to ICMC ………………………. Bank account number_____________________ 2. Once your membership is approved, you will be given a membership number and certificate indicating your status 3. You will be required to pay the membership fee of 2000ksh and consequently 3,000Kshs as an annual membership contribution. For further information, please contact the ICMC.Consent* I agree to the privacy policy & declaration. Show Full AgreementPRIVACY POLICY Persons who supply data in their application to the Mediation Accreditation Committee are advised to note the following points. 1. Personal data provided in this application form will be used solely for the purpose of assessment for accreditation as a Mediator, and in this connection the data herein will be dealt with by the ICMC staff and/or by the Membership and recruitment Committee members. 2. After an application for assessment has been duly processed, the application papers of the candidates will be retained in a file established by the ICMC membership and recruitment Committee for each applicant. Such information will be retained by ICMC Committee for as long as it deems necessary or useful. 3. An applicant has the right to request access to, and the correction of, his/her personal data as retained by the ICMC membership and recruitment Committee. Declaration 1. I have read and agreed to the Personal Data Notice. 2. I authorize the ICMC membership and recruitment Committee, ICMC staff, employees and/or members of the ICMC Committee to deal with, utilize and/or assess the data submitted by me as may be required in connection with my application for membership as a mediator. 3. I understand that my data will become a part of the ICMC Committee records and may be used for all purposes deemed necessary or useful by the ICMC membership and recruitment Committee. 4. I declare that the information given in support of this application is accurate and complete. I understand that any misrepresentation will disqualify my application and may lead to revocation of my membership as a mediator, should I be enrolled. ICMC membership and recruitment Committee also reserves the right to report the matter to my professional body/association. 5. Any information on this form may be made available by ICMC membership and recruitment Committee to third parties for the purposes of mediator assessment or selection. 6. I have no previous criminal convictions for crimes of dishonesty, violence or misuse of drugs. I have no criminal cases pending against me. I undertake to inform ICMC membership and recruitment Committee if I am charged with any criminal offences during the time that I am enrolled to the ICMC mediator membership. 7. I confirm that there are no disciplinary actions against me by any professional body.
