[See section 12 (1)(b)]
Name:
Contact Details:
Prior Experience (Including Experience With Arbitrations):
Number Of Ongoing Arbitrations:
Circumstances disclosing any past or 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 justifiable 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):
