Mediators Panel Application Form

Particulars of the Applicant

Please select the appropriate category:

Domestic Mediation Panel

International Mediation Panel

Both

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First Name

Last Name

Nationality

Personal Email

Occupational Details of the Applicant

Name of employee

Postal Address

City

Country

Work Email

Office Line

Primary Occupation

Education

Degree / Certificate (s)

Year Awarded

Institution

Please attach copies of certificates

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Mediation Training

Qualification

Year Awarded

Name of Institution

Attach Proof of training

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Have you been involved in mediation as:

Facilitator

Trainer

Instructor

Other

If Other, please specify

Mediation Experience

Indicate the number of arbitration if you any you have acted in the areas below

As a sole Mediator

Commercial

Other (Specify)

Construction

Investor / state

As a Co-Mediator

Commercial

Other (Specify)

Construction

Investor / state

As a Counsel Agent

Commercial

Other (Specify)

Construction

Investor / state

Provide a brief outline / profile of disputes you have handled as an arbitrator

Type of Dispute (e.g Breach of Contract)

Issues and Nature of Evidence

Duration and value of dispute

Number of years you have acted as a mediator?

Please attach a one-page resume / curriculum vitae / profile

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Are you a certified/accredited mediator or listed in the panel of any other arbitral/Arbitration institution?

Yes

If yes, please specify

Is Mediation currently your primary (full-time) practice?

Yes

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

Recommendation

Please provide at least two references who attest to your arbitration experience

Name of Referee

contact

Email Address

Declaration

I consent to ICAMEK using any of my personal information that I may have provided in this application for the processing of my application, background and reference checks, for the purposes of future appointments (if any) in any mediation handled by ICAMEK and for the listing of my curriculum vitae on ICAMEK's website. Should my application be successful, i consent to ICAMEK's provision of my personal information to third parties when requested to do so in connection with such purposes

I understand that ICAMEK does not provide employment for any Mediator. I also understand the decision to nominate or appoint a Mediator(s) to any Mediation referred to ICAMEK is within the exclusive discretion of ICAMEK

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 ICAMEK Panel of Mediators

I agree, if admitted to ICAMEK Panel of Mediators, to be bound the ICAMEK Code of Conduct for Mediators, ICAMEK(Mediation) Rules, 2018 or there amendments or alterations from time to time and any other professional or legal requirement to which I am subject.

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Mediators Panel Application Form

Particulars of the Applicant

Occupational Details of the Applicant

Education

Mediation Training

Mediation Experience

As a Co-Mediator

As a Counsel Agent

Provide a brief outline / profile of disputes you have handled as an arbitrator

Recommendation

Declaration