Arbitrator Statutory Disclosure Form

BEFORE THE LD. SOLE ARBITRATOR

Mr/Ms/Mrs. ____________

[Claimant]

VERSUS

[Defendant]

DISCLOSURE UNDER SECTION 11(8) READ WITH SECTION 12(1) OF THE ARBITRATION & CONCILIATION ACT, 1996

(IN THE FORM SET OUT IN THE SIXTH SCHEDULE TO THE ACT)

Name:

Contact details: Address, Mobile, Email

Prior Experience (Including experience with Arbitrations):

Number of ongoing Arbitrations:

Circumstances disclosing any past of present relationship with or interest in any of the parties or in relation to the subject matter in dispute, whether financial, business, professional or other kind, which is likely to give rise to substantial doubts as to your independence or impartiality (List Out):

Circumstances which are likely to affect your ability to devote sufficient time to the arbitration and in particular your ability to finish the entire arbitration within twelve months (List Out):