If you are a qualified mediator interested in joining MiEA:

1. Complete this short online form then press 'Send'
   
   
Send by post:
• copies of your certificates (as identified on the form) and
  
• a cheque for £100 payable to HOWES PERCIVAL to:
  
  The Company Secretary
  Mediators in East Anglia
  c/o Howes Percival (Ref: AJB)
  The Guildyard
  51 Colegate
  Norwich
  NR3 1DD

(or DX 5280 Norwich)

Name
Address
e-mail
Telephone
Date of Birth
Training Body
Address of Training Body
Details of training and accreditation/registration Send copy of certificate or letter from training body
Other professional or relevant qualifications and information that may be helpful in the consideration of your application
Areas of expertise or special interest
In which geographical areas could you work?
Do you carry professional indemnity insurance? Send copy of certificate or letter from insurer	Yes No
Renewal date?
Tick to confirm what you intend to send to MiEA:	Insurance documents Training certificate £100 fee Other amount Already paid
Tick to confirm that the information given on this form is true and accurate