Personal Details

Title: First name: Surname:

Age | Sex:

Nationality:

Primary Occupation:

Address:

Telephone/Mobile: Fax:

E-mail:

Professional Details

Accreditation | Certification:

Panel member of Institution:

Countries / Regions
of practice*:

Languages known:

Applicable Fee Rate/Schedule*:

Area of expertise:

Professional Affiliations:

* In the order of preference

* Separate fee schedule may be applcable only for international arbitrators. For domestic arbitrators IIAM Arbitrator Fee
Schedule will be applicable. International arbitrators can also adopt IIAM Arbitrator Fee Schedule. IIAM Arbitrator Fee Schedule
can be seen at www.arbitrationindia.com/pdf/arbitration_fee.pdf
 Declarations by the Arbitrator

Any restrictions on quantum of claim

or type of disputes:

Willing to become Emergent Arbitrator:

Willing to abide by IIAM Arbitration Rules:

Willing to abide by IIAM Fee Schedule:

Willing to undertake out-station Arbitration:

Special Instructions:

Present position & background: (Attach separate sheet)

(A brief profile)

The facts stated above are correct. I have read and understood the terms and hereby agree to be bound by its terms.

Date: Signature:

• Attach separate sheets if required

• Empanelment would be provisional and will be at the sole discretion of IIAM

Please send the completed form to: Indian Institute of Arbitration & Mediation
G-254, Panampilly Nagar, Cochin 682 036, India
Tel: +91 484 4017731 | Email: dir@arbitrationindia.com