PANELS: REGISTRATION OF INTEREST

Please allow 15-20 minutes to complete this form. The form needs to be completed in a single session (although some browsers may remember what you have typed, you cannot save the form in progress to complete it later).
Documents you will need:
- Updated CV/Resume
- Updated profile photo (you can also send this later)

IF YOU ARE APPLYING FOR ICRA’S:
· ACC review panel, you will need to provide redacted copies of two decisions you have issued in the last 12 months;

· Any mediation panels, you will need to provide redacted copies of two settlement agreements you have completed in the last 12 months;

· Other panels (ie Complaint Management, Conflict Management, Organisational Reviews, Independent Reviews), you will need to provide redacted copies of two reports you have completed in the last 12 months.


Information you will need:
- Email and phone number of two referees; and
- Confirmation that you are currently a member of a Professional Membership Body.

Contact Details

In this section you will be asked to provide us with your relevant contact details. Please note that email is our primary means of communication and for service of any documents. Should your contact details change at any time, please ensure you inform the Case Management staff as soon as possible. In this section we also ask for information as to your age, gender, and nationality. Provision of this information is entirely optional. It is sought simply to better enable us to collate statistics on diversity of appointments.
Title
Mr, Ms, Prof, Dr, Sir, etc
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First Name
Your first name
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Last Name
Your last name / surname
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Suffix
eg QC, SC, MNZM
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Phone Number
Your phone number
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Mobile Number
Your phone number
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Email
–enter your email address–
enter a valid email address
enter a valid email address
Address
–type address–
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Nationality (optional):
–type here–
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Gender (optional)
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Date of Birth (optional)
–select the date–
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PANELS

Please select from the options below which panels you wish to apply for:

Choose at least one panel
Choose at least one panel

PROFESSIONAL BACKGROUND

Please provide information about your background and qualifications to support your application.
Qualifications
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Relevant Experience
Please summarise your relevant experience
type here
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CV/Resume
Please upload your updated CV/Resume
Upload file here...
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Redacted Decisions: if you have not previously published a decision with ICRA or any of the NZDRC Group Registries within the past 12 months, please upload redacted copies of two decisions you have completed in that time frame.
If you have not completed any decisions previously, please provide us with redacted copies of any similar documents to demonstrate your decision writing ability.
To upload more than one document, simply repeat the "Upload" action
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Redacted Settlement Agreements: please upload redacted copies of two settlement agreements you have completed within the past 12 months.
If you have not completed any settlement agreements previously, please provide us with redacted copies of any similar documents to demonstrate your knowledge of the requirements for an effective, valid and binding settlement agreement (this may include a mock example if necessary).
To upload more than one document, simply repeat the "Upload" action
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Redacted Reports: if you have not previously completed report with ICRA or any of the Registries of the NZDRC Group within the past 24 months, please upload a redacted copy of two reports completed within the past 12 months.
If you have not completed any reports previously, please provide us with redacted copies of any similar documents to demonstrate your report writing ability.
To upload more than one document, simply repeat the "Upload" action
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PROFESSIONAL OVERSIGHT
ICRA is not a membership body and does not provide professional disciplinary oversight. As such, and to ensure our clients receive the highest quality service, it is a prerequisite to being on our panels that you are a member of a relevant professional body.
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I confirm that I am currently a member of a relevant professional body.*
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Professional Memberships*
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Other professional memberships (if any)
Enter the name of other organisations here
you need to be a member of a professional body
you need to be a member of a professional body
Are you currently, or have you previously been, the subject of any professional disciplinary action or complaint arising from the provision of the services you offer?*
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If so, please provide details:
type here
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Would you like to submit your photo and bio for your online profile now?
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WEBSITE PROFILE

If you are successful with your application, your Profile and Profile Photo may be published on the ICRA website. Please note that we reserve the right to decline to publish any aspect of your Profile as submitted in this form. By providing us with a short bio and profile photograph, you consent to that information being published on our website and used for general marketing purposes.
Profile for ICRA Website*
Please set out your profile in paragraph format (rather than bullet points). Your profile should be limited to 800 characters (approx 120 words). If you are successful with your application, your profile will appear on the ICRA website.
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Profile Photo
Your photo will be used online.
Upload your documents...
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AREAS OF EXPERTISE

Please select below your relevant areas of experience and expertise.
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I have specific expertise in working with the following cultural, religious, ethnic, or gender groups:
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LANGUAGES

Languages:
Please only include the languages you are proficient in for the delivery of professional services.
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-
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Enter other languages with professional or native proficiency level
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Other languages at conversational level only
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LOCATION OF PRACTICE

GEOGRAPHICAL AREAS OF PRACTICE WITHIN NEW ZEALAND
I can work in the following locations as part of my usual place of practice (ie without requiring travel disbursements).
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Other location
type here
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TRAVEL REGIONS
I can travel to the following regions subject to travel and expense disbursements.
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Travel within New Zealand
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Other regions I can travel to
type here
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Room availability
Do you have your rooms available for the provision of your services?
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Is there any charge?
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Please indicate the room/s location (city or town)
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REFEREES

Please provide details below for two referees. By providing this information you consent to us contacting these referees for the purposes of processing your application.
First Referee
Title
Mr, Ms, Prof, Dr, Sir, etc.
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First Name
First Name
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Surname
Surname
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Email*:
Enter email of first referee
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Confirm email
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Phone Number*
Enter phone number
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First Referee:
Please set out below a brief description of your referee's role and relationship to you.
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Second Referee
Title
Mr, Ms, Prof, Dr, Sir, etc.
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First Name
First Name
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Surname
Surname
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Email*:
Enter email of second referee
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Confirm email
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Phone Number*
Enter phone number
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Second Referee:
Please set out below a brief description of your referee's role and relationship to you.
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CONFIRMATION AND SUBMISSION

I consent to ICRA using any of my personal information provided in this application form for the purpose of ICRA providing its services. Such use may include processing my application, creating a bio on ICRA's website, making appointments, and general marketing.
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I understand that admission to any of ICRA's panels is at the sole discretion of ICRA, that any such decision is final, and that ICRA is not required to provide any reasons for its decision.
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IMPORTANT: This form contains some mandatory fields, and it will not be submitted until those fields are completed. You will receive an email with a copy of your submission once the form goes through. Please advise if any information needs to be corrected.
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