Enlistment Form

Title:

Mr Mrs Miss Ms Other (please specify)

Given name:

Other names:

Surname:

Gender:

Male Female

Date of birth (dd/mm/yy)

Nationality:

Contact details

This will be your mailing & billing address. It will also dictate your annual subscription rate and branch allocation. Once admitted into enlistment, you may update where you have your correspondence sent to, through your online profile.

Address:

Town/city:

Postcode/zip:

County/state:

Phone:

Email Address:*

Facebook ID:

Twitter ID:

LinkedIn ID:

Part B: Panel Type

Please tick the of the following Categories you wish to enlist:

Arbitrator Negotiator Legal Executives

Mediator Expert Witness ADR Counsel

Adjudicator Secretary Diplomat

Professional Qualification

Please tick the one or more of the following Categories you wish to join:

Professional Membership

Name of Organization

Position/Title

Date of membership

Membership number

Part C: ADR Academic Profile

Name of Course/Training Title

Name of Course/Training Provider

Date of Completion

Field of Expertise

Please select areas of specialiation.

Part D: ADR Experience (Arbitration, Mediation, Adjudication, Negotiation)

Number and nature of cases in which you participated as an Arbitrator, Mediator, Adjudicator and/or ADR Counsel in the last 5 to 20 years. Please note: - Where the arbitration has been under an ADR institution; please provide the reference number for each case. - Where the arbitration is Ad Hoc; please provide an abbreviated reference of the parties without violating confidentiality.

ADR Institution Name and/or Case Ref. No

Nature of dispute

Approximate sum in dispute

Date of Decision/Award

*If further information is required, the candidate may be individually contacted for an interview. Such interview may be face to face or otherwise. Further, the candidate might be asked to submit up to three sanitized awards that he/she had rendered from the list set out above.

Language

Name of Language	Writing			Speaking			Reading
Name of Language	Excellent	Good	Fair	Excellent	Good	Fair	Excellent	Good	Fair

Checklist

Please check to ensure the following have been carried out before the form is sent to CiADR:

All sections of the form have been completed

You have completed the Data Protection Act questions

You have enclosed all copies of relevant certificates and documents

You have signed and dated the form

Any others documents

Part E: Declarations

Upload Your Photo:

Signature:

Date:

I agree to Terms & Conditions