APPLICATION FOR EMPANELMENT OF MEDIATOR FOR THE DISTRICT

CONSUMER MEDIATION CELL, SANGRUR

Passport
Size
Photograph

1. NAME

A) FATHER’S NAME
2.
B) HUSBAND’S NAME

3. DATE OF BIRTH

4. PERMANENT ADDRESS AND HOME DISTRICT

ADDRESS FOR CORRESPONDENCE WITH

5.
MOBILE NUMBER AND EMAIL ID

PRESENT OCCUPATION AND ANNUAL

6.
INCOME

ACADEMIC QUALIFICATIONS WITH DETAILED MARKS OBTAINED IN BACHELOR’S DEGREE/LAW

7. DEGREE FROM A RECOGNIZED UNIVERSITY AND POST-GRADUATION, IF ANY.
TOTAL MARKS
PASSING
COLLEGE/UNIVERSITY DEGREE OBTAINED WITH REMARKS
YEAR
PERCENTAGE

EXPERIENCE OF MEDIATION AND IN HIS/HER

8.
ACADEMIC FIELD/SERVICE/PROFESSION
HAVE YOU EVER HELD CIVIL POST UNDER
STATE OR CENTRAL GOVERNMENT / BOARD /
9.
CORPORATION?
IF YES, GIVE DETAILS
HAVE YOU EVER OBTAINED ANY TRAINING
OF MEDIATION?
10.
IF YES, GIVE DETAILS AND ATTACH THE
REQUISITE CERTIFICATES OF TRAINING
NUMBER OF CASES HANDLED (IN CASE OF
11.
ADVOCATE)

ANNUAL INCOME FROM ALL SOURCES.

12.
COPY OF INCOME TAX RETURN, IF ANY

13. PERMANENT ACCOUNT NUMBER (PAN)

14. ANY OTHER INFORMATION

STATE CONSUMER DISPUTES REDRESSAL COMMISSION PUNJAB, CHANDIGARH (2021)

15. AN AFFIDAVIT BE ALSO SUBMITTED ALONGWITH THE APPLICATION, TO THE FOLLOWING EFFECT:

(I) THAT HE/SHE HAS NOT BEEN ADJUDGED AS INSOLVENT;

(II) THAT AGAINST HIM/HER NO CRIMINAL CHARGES INVOLVING MORAL TURPITUDE ARE FRAMED
BY A CRIMINAL COURT AND ARE PENDING;
(III) THAT HE/SHE HAS NOT BEEN CONVICTED BY A CRIMINAL COURT FOR ANY OFFENCE INVOLVING
MORAL TURPITUDE;
(IV) THAT AGAINST HIM/HER NO DISCIPLINARY PROCEEDINGS HAVE BEEN INITIATED BY THE
APPROPRIATE DISCIPLINARY AUTHORITY AND ARE NOT PENDING OR HAVE NOT RESULTED IN A
PUNISHMENT.

16. BEFORE ENTERING UPON MEDIATION, THE MEDIATOR IS REQUIRED TO FILE AN AFFIDAVIT AS PER
REGULATION 4(2) OF CONSUMER PROTECTION (MEDIATION) REGULATIONS, 2020.

DATE: SIGNATURE OF APPLICANT

VERIFICATION:
VERIFIED THAT THE INFORMATION GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE
AND NOTHING HAS BEEN CONCEALED THEREFROM. IN CASE, THE INFORMATION OR ANY PART
THEREOF IS FOUND FALSE THEN IT MAY BE TREATED DISQUALIFICATION.

DATE: SIGNATURE OF APPLICANT

NOTE:

I. SELF-ATTESTED COPIES OF RELEVANT DOCUMENTS IN SUPPORT OF PROOF OF AGE, ACADEMIC

QUALIFICATIONS, EXPERIENCE, INCOME ETC. BE ATTACHED, SPECIFICALLY FOR ADVOCATES, THE
EXPERIENCE CERTIFICATE FROM CONCERNED BAR ASSOCIATION SHOULD BE ATTACHED.

II. THE CANDIDATE MUST READ CAREFULLY THE PROVISIONS OF CONSUMER PROTECTION ACT,
2019, CONSUMER PROTECTION (MEDIATION) RULES, 2020 AND CONSUMER PROTECTION
(MEDICATION) REGULATIONS, 2020 FOR ELIGIBILITY AND DISQUALIFICATION.

INTERVIEW LETTERS TO THE ELIGIBLE CANDIDATES WILL BE ISSUED SEPARATELY, IN DUE COURSE OF
TIME.

Superintendent
District Consumer Commission,
Sangrur (Pb) -148001.
Phone: 01672-231432
Email: confo-sa-pb@nic.in

STATE CONSUMER DISPUTES REDRESSAL COMMISSION PUNJAB, CHANDIGARH (2021)