COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

APPLICATION FOR PRIVATE CUSTODY EVALUATOR APPOINTMENT LIST

Pursuant to Rule 91 of the Ohio Rules of Superintendence and Hamilton County Court of Domestic Relations Local Rule Title II, I hereby apply for appointment as a private custody evaluator.

Name:	Telephone:

Profession:	Cell Phone:

License No.:	Fax:

Office Address:	Email:

This application includes:

(1)	a resume stating the applicant’s education, experience, training, expertise, and licensure demonstrating compliance with the Court’s Local Rule and demonstrating the applicant’s ability to successfully perform the duties and the responsibilities of a private custody evaluator;

(2)	a copy of the applicant’s certificate of completion of the Supreme Court of Ohio 40-hour pre-appointment training;

(3) a copy of the applicant’s malpractice insurance; and

(4) a copy of current licensure.

Incomplete applications will not be accepted and will be returned to you for completion.

I certify all the above information is accurate and am unaware of any circumstances that would disqualify me from serving as a custody evaluator. I have completed the pre-education and/or continuing education requirements set out in Superintendence Rule 91.08 and 91.09, a statement of which I have provided to the Court. I understand my obligation to complete at least six hours of continuing education annually provided by the Supreme Court of Ohio or other provider approved by the Supreme Court.

Signature	Date