Idaho Mediation Association
 
 
 208-855-0506   
 

                                        IDAHOMEDIATION ASSOCIATION

                                     AFFIDAVIT OF COMPLIANCE

 

STATE OF _______________________________ )

 

COUNTY OF ______________________________ )

 

I, ____________________________, being first duly sworn, depose and say:

I am the person named who has signed this application for approval of continuing education credit by the Idaho Mediation Association (IMA). By signing this application, I attest that I have fulfilled the requirements set out in the application form upon which I have submitted my name, and agree to continue to abide by Idaho Mediation Association Ethics and Standards of Practice and Grievance Procedure. 

 

I understand that the determination as to whether I continue to be certified as a Professional Mediator depends on the truth, falsity, or completeness of my answers set forth in this application and the statement attached.

 

To my knowledge, the answers and information which I have supplied in connection with this application are true and complete.

 

Applicant's Signature: ________________________________________

 

Date: ____________________________

Subscribed and sworn to before me this ______ day of ____________ , ______

 

 

 

 

 

 

 

(SEAL)

 

_____________________________ NOTARY PUBLIC SIGNITURE

_____________________________ RESIDING AT

_____________________________ MY COMMISSION EXPIRES


Idaho Mediation Association
Hoff Building
802 W. Bannock St., Ste. 303
Boise, Idaho 83702
(208) 855-0506
admin@idahomediationassociation.org

In-office hours:
By appointment only.

Mailing Address:
P.O. Box 2504
Boise, Idaho 83701-2504

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