STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102
(702) 486-4480 / Toll free: (877) 829-9907 / Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://red.nv.gov
Page 1 of 5 Form 522A
ALTERNATIVE DISPUTE RESOLUTION
REFEREE/ARBITRATOR APPLICATION FORM
(Please Print or Type)
Name:
Address:
City: State: Zip Code:
Daytime Number: Fax Number: Cell:
Email Address:
NEVADA BAR ID #: Current Member Status (must be in good standing):
COMPANY/BUSINESS INFORMATION:
Company Name:
Address:
City: State: Zip Code:
Contact:
Phone Number: Fax Number:
Email Address:
CONTRACT INFORMATION: (Information listed here will appear on your contract)
Contractor Name:
Address:
City:
State: Zip Code:
Contact:
Phone Number:
Fax Number:
Email Address:
Current Specializations:
Revised 4/27/2021
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102
(702) 486-4480 / Toll free: (877) 829-9907 / Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://red.nv.gov
Revised 4/27/2021 Page 2 of 5 Form 522A
List major area of specialization or subject expertise related to homeowner association knowledge/operation (real estate,
CC&Rs, bylaws, budgets, accounting, injuries, construction, insurance, etc., as well as NRS 116):
QUALIFICATIONS:
List any formal training or classes attended (referee/arbitrator programs) on the hearing of cases/claims and issuance of
decisions. Include copies of certificates with the application as proof of completion.
Course/Training Title
Date
Hours
Provider Name
Attach additional training information if applicable.
Are you a member of a Mediation/Arbitration organization or service? Yes No
Name:
Address:
City: State: Zip Code:
Phone: Length of Membership with Service:
Please indicate if you would like to be considered for the ADR Arbitration Panel: Yes No
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102
(702) 486-4480 / Toll free: (877) 829-9907 / Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://red.nv.gov
Revised 4/27/2021 Page 3 of 5 Form 522A
Please describe any experience with the resolution of disputes (referee and arbitrator services for an Alternative Dispute
Resolution (ADR) program) between parties in a professional capacity such as business, employment, insurance, real
estate, and business dissolutions. Also describe any experience with the resolution of disputes concerning Homeowner
Associations, including, and without limitation, the interpretation, application, and/or enforcement of the covenants;
conditions and restrictions pertaining to residential property as well as the articles of incorporation, bylaws, and rules and
regulations.
GEOGRAPHIC SERVICE AREA:
Reno/Carson/Tahoe Area Central Nevada Northeastern Nevada Greater Las Vegas Area
Please list foreign languages or sign languages and level of fluency:
QUESTIONNAIRE:
1. Are you presently employed by the State of Nevada, any of its political subdivisions, or by
any government agency?
Yes No
If yes, please explain and list agency/department:
2. Were you formerly employed by the State of Nevada within the last 24 months?
Yes No
If yes, please explain and list agency/department:
3. Have you been engaged under contract by any State Agency?
Yes No
If yes, please explain and list agency/department:
4. Are you presently involved in any litigation with the State of Nevada?
Yes No
If yes, please explain and list agency/department:
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102
(702) 486-4480 / Toll free: (877) 829-9907 / Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://red.nv.gov
Revised 4/27/2021 Page 4 of 5 Form 522A
All applicants MUST complete this section.
INSURANCE:
Workers Compensation
Affidavit of Rejection of Industrial Insurance Coverage OR
Insurance Certificate - Expiration Date:
Commercial Liability
Insurance Certificate - Expiration Date:
Professional Liability/Errors and Omissions Liability
Insurance Certificate - Expiration Date:
NEVADAEPRO:
Are you registered with the State of Nevada’s electronic procurement system, NevadaEPro? Yes No
My NevadaEPro Vendor ID number is:
NevadaEPro registration is required. Vendors must be registered in NevadaEPro to respond to bid solicitations posted
by the State of Nevada. NevadaEPro is available to register your company to receive future solicitation notifications,
respond to solicitations, provide quotes, and receive purchase orders or contracts. Go to https://nevadaepro.com.
Please direct questions from the NevadaEPro registration to State Purchasing at https://nevadaepro.com. State
NEVADA STATE CONTROLLER’S OFFICE – DATA WAREHOUSE OF NEVADA (DAWN):
Are you registered with DAWN? Yes No
My Nevada State Controller’s Vendor number is:
All vendors receiving payment from a State agency must complete a State of Nevada Vendor Registration form per IRS
compliance. This record will be used by all State agencies to make payments to you.
You can contact Vendor services at (702) 486-3895 or vendordesk@controller.state.nv.us.
State Registration Vendor Information must be consistent.
Does your company name and address match in NevadaEPro, in DAWN, and on the contract? Yes No
If there are inconsistencies, please explain:
STATE OF NEVADA
DEPARTMENT OF BUSINESS AND INDUSTRY - REAL ESTATE DIVISION
OFFICE OF THE OMBUDSMAN FOR COMMON-INTEREST COMMUNITIES AND CONDOMINIUM HOTELS
3300 W. Sahara Avenue, Suite 350, Las Vegas, NV 89102
(702) 486-4480 / Toll free: (877) 829-9907 / Fax: (702) 486-4520
CICOmbudsman@red.nv.gov http://red.nv.gov
Revised 4/27/2021 Page 5 of 5 Form 522A
NEVADA SECRETARY OF STATE:
Are you registered with the Nevada Secretary of State? Yes No
Legal Entity Type:
NV Corporation (Domestic Corporation)
LLC
LLLP
Other
Foreign Corporation
LP
Sole Proprietor
Non-Profit Corporation
LLP
Governmental Entity
If Other, please list entity type or explain:
Is the legal entity active and in good standing with the Nevada Secretary of State’s Office? Yes No
Do you have a current Nevada business license number assigned by the Nevada Secretary of State? Yes No
My Nevada business license number is:
Do you have a current Certificate of Business (Fictitious Firm Name)? Yes No
My FFN Instrument Number is:
List Other Relevant Business Licenses and Business License Numbers:
APPLICANT DECLARATION:
I CERTIFY that the above information and any other information I am submitting for this application
is true and correct to the bet of my knowledge and that I may be removed from the Referee panel or
Arbitrator panel for intentionally falsifying the information provided. False certification may also
subject me to civil or criminal penalties. I understand that all the information provided is a public
record. I agree to comply with all provisions of NRS Chapter 38.
INITIAL
State of SS. COUNTY OF
This instrument was acknowledged before me on (date) , in the possession of applicant (Notary prints the
name of the person who presents the document) .
(Notary Stamp) Signature of Notarial Officer
