Mediator Panel Status Application Form

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(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.)


(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

(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.

Yes No
Yes No



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