Application Form - MyMediation™ Accreditation Course
 Thank you for choosing to apply for this Accreditation Course. The application may take approximately 20 to 40 minutes to complete, and please note that there is no option to save your progress. Kindly consider this when initiating the application.
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Name *
First and last name
Your ABN
 *
If you are not registered for an ABN, please type "N/A"
Email *
Phone number *
Address of practice
 *
This is the address associated with your ABN. If you are not registered for an ABN, please list the address from which you will practice from most of the time. This can be your residential address.
Gender
 *
Do you currently provide mediation services? *
Are you a Nationally Accredited Mediator in Australia?
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If you are an Accredited Mediator in a country (or countries) other than Australia, please list:
What is your right to work status in Australia?
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Do you have a current Australian National Police Clearance?
 *
If not, please indicate "No", but you must be willing to obtain.
Do you have a professional indemnity insurance policy?
 *
Highest level of completed education
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Please list your highest qualifications and year of completion
Explain your employment history or business experience (Limit 500 words)
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Languages spoken
 *
Please only list languages that you are proficient in, and in which you would be able to mediate.
Required
How would you describe your comfort level with using technology for online meetings and attending courses online? *
Do you have a disability that may pose challenges for your attendance in this course?
*
If yes, please specify the nature of the disability to help us better accommodate your needs and ensure a supportive learning environment.
Closest major city to your home
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Please tick all capital cities that you are willing to travel to for face-to-face components of the training.
Required
Have you participated in a mediation session in any capacity before? *
Which modules of the course are you applying for?
In your own words, what are the main reasons you want to complete this course? (Limit 500 words)
*
Professional Reference 1
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Please list name, professional relationship with you, company/organisation, job title, email and phone number.
Professional Reference 2
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Please list name, professional relationship with you, company/organisation, email and phone number.
Regarding payments for the Accreditation Course(s), what is your preference?
If you choose to make monthly installment payments via Emdex Capital, one of our representatives will be in contact with you to arrange this process. Emdex Capital is a Matilda Group company and is established to assist funding of payments for Matilda Group companies clients.
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Declaration *
I confirm that the information I provided in this application is accurate and complete to the best of my knowledge. I understand that providing false information may result in the rejection of my application or, if accepted, in the termination of my relationship with MyMediation™. If terminated, I acknowledge that I may not be eligible for a refund. I will promptly update MyMediation™ with any changes to my information. I acknowledge that this application is solely an expression of interest and does not guarantee me a position in the course, and that further steps may be necessary before my final acceptance. 

Furthermore, I read, and do accept all terms and conditions of the MyMediation Accreditation Courses which I obtained by clicking on this link: (T&C Link).
Required
Signature
 *
Please enter your full legal name below; this serves as your electronic signature for this online form.
Submit
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