PIArb

PHILIPPINE INSTITUTE OF ARBITRATORS, INC.

Membership Application Form

1. Title:……………………………………………………………………………………………………….

2. Family Name:

……………………………………………………………………………………………..

3. Other Name(s):…………………………………………………………………………………………...

4. Date of Birth (dd/mm/yyyy):…………………./………………../………………..

5. Job Title:………………………………………………………………………………………………….

6. Firm/Company:…………………………………………………………………………………………..

7. Address (line 1):………………………………………………………………………………………......

8. Address (line 2):………………………………………………………………………………………......

9. Town/City:……………………………………...10. Country/State:……………………………………

11. Postcode/Zip:…………………………………..12. Country:………………………………………….

13. Telephone (daytime):…………………………...14. Telephone (home):………………………………

15. Fax (daytime):…………………………………...16. Fax (home):……………………………………...

17. Email:……………………………………………………………………………………………………

18. Preferred Method of Communication (please indicate by ticking one box):

[] Post [] Email [] Fax [] Telephone

19. Business sector (please indicate by ticking one box):

[] Academic [] Agriculture [] Banking/Finance [] Commodities
[] Commercial (manufacturing) [] Commercial (retail) [] Construction [] Dental/Medical
[] Engineering [] Insurance [] I.T./Communications [] Land/Property
[] Law [] Maritime [] Media/Marketing [] Sport
[] Other (please state):

20. Languages: ……………………………………………………………………………………………...

21. How did you hear about The Philippine Institute of Arbitrators, Inc.? (Please indicate by ticking
one box):
[] Word of Mouth [] Chartered Institute of Arbitrators
[] Internet [] Advertisement (publication name/date)………………………………...
22. Please list relevant academic and professional examinations completed:

Title of Examination Education body Date Passed Grade

……………………………………/…………………………../…………………………./

…………………

……………………………………/…………………………../…………………………./

………………………………………………………/…………………………../

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…………………………./…………………23. Membership in Professional or Occupational

Institutions:

Title of Organization Date Admitted Membership Grade

……………………………………/…………………………../…………………………

……………………………………/…………………………../………………………….

……………………………………/…………………………../………………………….

24. Knowledge of Arbitration or Other Private Means of Dispute Resolution

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

25. Practical Experience in Arbitration or other Private Means of Dispute Resolution

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

………………………………………………………………………………………………………………

26. Prior Conduct:

(a) Have you ever been expelled from or disciplined/reprimanded by a regulatory or professional body?

(b) Has an application for insolvency ever been made against you or has a company, of which you were a

Director, gone into compulsory or voluntary receivership or liquidation on grounds of insolvency?

(c) Are there any outstanding judgments against you?

(d) Have you ever been convicted of any offense in any court or sanctioned in any administrative proceeding? Please
27. Do you consent to your name and contact details appearing in the Institute’s Online Directory of

Members?

[] YES [] NO Signature:……………………………………………………………………………………….

28. Do you consent to receiving marketing material sent from the Institute by:

- Post [] YES [] NO

- Electronic Communication (fax, email) [] YES [] NO Signature…………………………….

29. To maximize the benefits that members receive, the Institute sometimes exchanges contact information with

other relevant organizations. Do you consent to your name and address being passed to third parties?

[] YES [] NO Signature…………………………………………………………………………………………….

30. List of Attachments (if any):

31. Declaration: I, the undersigned, hereby apply for admission to membership of the Philippine Institute of

Arbitrators, Inc. If admitted, I agree to comply with the Articles of Incorporation, By-laws, and Code of Professional

Conduct, and any subsequent amendments and/or alterations that may be made, and by any regulations made or to be

made for carrying them into effect.

I declare that to the best of my knowledge, the information given on this form is correct.

On admittance, I request that you issue me a Membership Certificate. I agree that the certificate will remain the

property of the Institute and will undertake to return it if I cease to be a member.

Signature………………………………………………………………… Date………………………………………….

PIArb
PIArb Secretariat
c/o Kalaw Sy Selva Campos Law Firm
West Tower 2106A, Phil. Stock Exchange Centre, Exchange Road, Ortigas Center, Pasig City, 1605 Phil.
Phone: (632) 687-7900; Fax: (632) 687-4077