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 credits 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 ____________ , ______










_____________________________ NOTARY PUBLIC SIGNATURE

_____________________________ RESIDING AT

_____________________________ MY COMMISSION EXPIRES

P.O. Box 2504, Boise, ID 83701

Idaho Mediation Association is a 501(c)6 non-profit organization.

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