7 – REQUEST FOR APPOINTMENT OF MEDIATOR/CONCILIATOR/FACILITATOR/NEUTRAL EVALUATOR/EXPERT DETERMINATOR/ADJUDICATOR/ARBITRATOR

The Parties have failed to agree on the appointment of an/a Arbitrator/Mediator/Conciliator/Facilitator/Expert/Neutral as required under their agreement in this matter, details of which are set out in the Request that has been filed herein.

I/We *

First

Last

and *

First

Last

hereby mutually request the JAIAC to appoint

CLAIMANT’S INFORMATION

Claimant *

First

Last

Address

Claimant

Email *

Claimant

Phone

Claimant

RESPONDENT’S INFORMATION

Name *

First

Last

Respondent

Address

Respondent

Email *

Respondent

Phone

Respondent

INDEMINITY CLAUSE

I/We further certify that in making the appointment as requested by the Parties, no liability will attach to the JAIAC or any of their servant or agents in respect of any fees, costs or expenses connected with this matter, including any fees that may become payable to the appointed [MEDIATOR/CONCILIATOR/FACILITATOR/NEUTRAL EVALUATOR/EXPERT DETERMINATOR/ADJUDICATOR/ARBITRATOR].

Claimant Signature

Date