…………………………….

, Advocate
Sole Arbitrator
……………………………………………………………………...
Date : …………………
Ref No. ARB – LA – Dec – …………………
1. M/s. …………………………………….
……………………………….,
…………………………,
………………………...
THROUGH ITS COUNSEL
M/s. …………………………………
……………………………………………,
……………………………………………..
To,
Mr. …………….
………………………,
……………………..,
………………………...
Sub : Notice under Section 21 of the Arbitration & Conciliation Act 1996, in the matter of
Arbitration between M/s. ……………………… & Mr. ……………..
In response to a letter dated …………………………. of M/s. ………………………………. appointing me
as Sole Arbitrator, I hereby accept my appointment as Sole Arbitrator in the disputes which have arisen
under and with respect to the written agreement in the Account No. ………………………….. entered
between the above said parties. Further the declaration as contemplated under Section 12 of the
Arbitration and Conciliation Act 1996 is as follows :-

Name ………………………, Advocate Enrol No. ………………………

Contact Details Office Chamber No. ……………………………
Prior Experience (including Undersigned is an Advocate, practicing in High Courts and
experience with Arbitration) various District Courts since 1994
Number of ongoing arbitrations More than five hundred
That M/s. …………………………… has appointed the undersigned as Arbitrator
That there are no circumstances which would affect my ability to devote sufficient time to the
Arbitration or which would affect my ability to complete the Arbitration Proceeding within the
stipulated period
That I have no relationship of any nature with any of the parties or counsel either presently or for
the past three years. I have neither have any relationship to the dispute or have any direct or
indirect interest in the dispute and I am independent and impartial

I hereby direct the parties to appear before me on …………………………. at 3.00 PM at Chamber No.
……………………………….