Mediator Panel Status Application Form

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PARTICULARS OF APPLICANT

First Name*

Middle Name

Last Name*

Category applying for *

Nationality*

ID/Pssport Number*

Other Nationality (if applicable)

Other ID/Pssport Number

Name of Firm (if applicable)

Mailing/Physical Address

Country*

City*

Postal Code

Telephone*

Fax

Email*

Primary Occupation*

EDUCATION

(i) Level of academic qualification **

Year Awarded	Degree/Certificate	Institution

(ii) Mediation training **

Year	Nature of training	Institution

(iii) Other training in dispute resolution **

Year	Nature of training	Institution

* You will be requested to provide proof of qualification and training during approval.
** (If you have been involved in such training as a facilitator, trainer or instructor, you will be requested to describe your role.)

MEDIATION EXPERIENCE

(a) Indicate the number of Mediations, if any, that you have acted and the role in the areas specified in the table below;

	Commercial	Construction	Investor/State	Other(Special)
Sole Mediator
Co-mediator
Counsel/Agent

(b) Provide a brief outline/profile of disputes you have handled as a mediator;

Type of dispute (e.g Breach of Contract)	Issues	Value of dispute	Nature of evidence *	Duration of dispute

* e.g. documentary, oral, witnesses.

c) Number of years you have acted as a Mediator? (Please attach a brief resume/curriculum vitae/profile).

d) Are you a certified/accredited Mediator or listed in the panel of any other mediation institution?

Yes No

If yes, provide particulars

e) Is mediation your primary (full-time) practice?

Yes No

OTHER INFORMATION

a) Outline any other relevant experience or provide any other information which supports your application (including where your Mediation experience involves disputes of an international character).

b) What is your preferred area(s) of practice as an Mediator?

c) Curriculum Vitae (CV)

DECLARATION

I understand the Nairobi Centre for International Arbitration does not provide employment for any Mediator. I also understand the decision to nominate or appoint a Mediator or Mediators to any Mediation referred to Nairobi Centre for International Arbitration is within the exclusive discretion of the Nairobi Centre for International Arbitration.

I hereby declare that the information provided herein is complete and accurate. I understand that a false statement may disqualify my application from consideration and I hereby give my consent to a personal investigation in connection with this application for NCIA Mediator Panel Status.

I agree, if accredited to NCIA Mediator Panel Status, to be bound by the terms and conditions applicable to NCIA Mediator Panel Status and to comply with the Mediator Panel Status Standard, the NCIA Code of Conduct for Mediators, Nairobi Centre for International Arbitration (Mediation) Rules, 2015 or there amendments or alterations from time to time and any other professional or legal requirement to which I am subject.

Check this box if you agree with all the above