IIAM EMPANELMENT FORM FOR NEUTRALS

Instructions

 Kindly complete all the information sought

 Kindly sign the first page of the Form and submit a duly completed scanned
copy of the first page of the Form. Submit the duly completed entire Form in (Photo)
word format, together with softcopy of your passport size photo in a jpeg
format
 Submission to be made in soft version addressed to the IIAM Executive
Director – dir@arbitrationindia.com

AGREEMENT, CONFIRMATION AND DECLARATION

I agree to accept the appointment to serve as:

Arbitrator

Emergency Arbitrator

Mediator

on the IIAM Panel of Neutrals and consent to the Indian Institute of Arbitration & Mediation (IIAM) using
and disclosing to third parties or exhibiting in the IIAM website, any information provided by me in this
Empanelment Form as may be reasonably necessary to carry out the activities and perform the services
of IIAM.

I am willing to arbitrate / mediate as per the IIAM Arbitration or Mediation Rules.

I understand that the empanelment will be at the sole discretion of IIAM.

I declare that the information given by me in this Empanelment Form is true to the best of my knowledge.

_______________________________________
Signature Date

Name Place

IIAM Empanelment Form for Neutrals 1

 PERSONAL PARTICULARS

In order to facilitate their appointment as neutrals, Panellists shall notify IIAM as soon as possible in the
event there is any change to their personal particulars.

First Name

Surname

Age / Sex

Designation / Position

Organisation

Telephone / Mobile number(s)

Email

Address

Country of nationality or ordinary

residence / State

City of residence / practice

Language(s) known

EMPANELMENT

Please select the neutral categories in which you would like to empanel.

Arbitrator Mediator

Emergency Arbitrator

ARBITRATOR / EMERGENCY ARBITRATOR Not

Applicable

Certified*
Accreditation - Certification
Not applicable

IIAM Empanelment Form for Neutrals 2

 *If Certified, details of certification

IIAM Arbitration Fee Schedule

Applicable Fee Schedule
Separate Fee Schedule*

*If Separate Fee Schedule, details of

Fee structure

Yes
Any restriction on quantum of claim
(Minimum amount of claim in a No
dispute under which to be appointed)

If Yes, the minimum amount

Yes
Any restriction on type of disputes
No

If Yes, type of disputes

(Specify types you want to include)

Arbitration experience
(Specify both domestic and
international)

Domestic: Yes No
Willing for outstation arbitration
International: Yes No

 IIAM Arbitration Rules can be downloaded from www.arbitrationindia.com/pdf/rules_arbitration.pdf

 IIAM Arbitration Fee Schedule can be downloaded from
www.arbitrationindia.com/pdf/arbitration_fee.pdf

MEDIATOR Not
Applicable

IMI Certified (Grade A)

Accreditation - Certification
IIAM Certified Senior Commercial Mediator

IIAM Empanelment Form for Neutrals 3

 IIAM Certified Commercial Mediator
IIAM Commercial Mediator (Grade B)
IIAM Certified Community Mediator
IIAM Community Mediator (Grade C)
Other certification*

*In case of other certification, details

Mediator training details

Facilitative Evaluative
Mediation styles
Transformative

IIAM Mediators Code of Professional Conduct

Applicable Code of Conduct
Other Code of Conduct*

*In case of other Code, details

IIAM Mediation Fee Schedule

Applicable Fee Schedule
Separate Fee Schedule*

*If Separate Fee Schedule, details of

Fee structure

Yes
Any restriction on quantum of claim
(Minimum amount of claim in a No
dispute under which to be appointed)

If Yes, the minimum amount

Yes

IIAM Empanelment Form for Neutrals 4

 Any restriction on type of disputes No

If Yes, type of disputes

(Specify types you want to include)

Mediation experience
(Specify both domestic and
international)

Domestic: Yes No
Willing for outstation mediation
International: Yes No

Yes, please send me the online submission form

Would like to empanel as mediator in
PeaceGate App (www.peacegate.in) No

 IIAM Mediation Rules and IIAM Mediators Code of Professional Conduct can be downloaded from
www.arbitrationindia.com/pdf/rules_mediation.pdf
 IIAM Mediation Fee Schedule can be downloaded from www.arbitrationindia.com/pdf/mediation_fee.pdf

SPECIAL INSTRUCTIONS / ADDITIONAL DETAILS Not

Applicable

IIAM Empanelment Form for Neutrals 5

 PROFILE

Please provide a brief bio-data (not exceeding 350 words)

IIAM Empanelment Form for Neutrals 6