Application Form for Panel of Mediators
| Personal information | |
| Name:
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| Affiliated organisation:
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| Job title:
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| Physical address:
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| Telephone:
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| Email:
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| Date of birth:
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| Nationality:
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| Place of residence:
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| Jurisdiction of admission:
(lawyers only)
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| Proposed hourly rate:
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| Mediator experience | |
| Experience as mediator
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Mediation Cases |
| No. of total appointments:
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| No. of mediation sessions conducted:
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| No. of mediated settlement agreements concluded:
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| Member of any other panel of mediators?
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| Other information about your experience as mediator:
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| Describe your other ADR expertise, if any (e.g. expert witness, arbitration, adjudication, domain name dispute resolution) | |
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| Describe your connection with Asia, if any | |
| List language(s) which you can speak, read and write professionally | |
| Referees | |
| Referee 1: | Name:
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| Contact details:
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| Referee 2: | Name:
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| Contact details:
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| Publication of information | |
| Would you be willing to have your personal information listed above published on ARIAS Asia’s website?
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Yes
No |
| Would you be willing to have your CV published on ARIAS Asia’s website?
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Yes
No
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| Checklist of required supporting documents | |
| Latest CV | Yes
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| Certificate of mediator accreditation
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Yes |
| Proposed terms of appointment (including hourly rate)
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Yes
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| Personal Data (Privacy) Ordinance Notice | |
| Individuals who supply data in their applications to ARIAS Asia are advised to note the following pursuant to the Personal Data (Privacy) Ordinance:
1. Personal data provided in this application form will be used solely for the purposes of assessment for panel listing, and in this connection the data herein will be dealt with by ARIAS Asia staff and/or Executive Committee. 2. After an application for assessment has been duly processed, the application documents of the applicants will be retained in a file established by ARIAS Asia for each applicant. Such information will be retained by ARIAS Asia for as long as it deems necessary or useful. 3. Under the provisions of the Personal Data (Privacy) Ordinance, an applicant has the right to request access to, and the correction of, his or her personal data as retained by ARIAS Asia. Applicants wishing to access or make corrections to their data should submit written requests to ARIAS Asia.
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| Declarations | |
| 1. I have never been found guilty by a court or disciplinary tribunal of misconduct.
2. I have read and agreed to the Personal Data (Privacy) Ordinance Notice. 3. I authorize ARIAS Asia, its staff, employees and/or members of ARIAS Asia Executive Committee to deal with, utilize and/or access the data submitted by me as may be required in connection with my application for the panel listing. 4. I understand that my data will become part of ARIAS Asia’s files and may be used for all purposes deemed necessary or useful by ARIAS Asia. 5. I declare that the information given in support of this application is accurate and complete. I understand that any misrepresentation may disqualify my application or lead to revocation of my membership of the Panel of Mediators, should I be listed. 6. Any information on this form may be made available by ARIAS Asia to third parties for the purposes of panel listing and selection.
Pleases sign below to confirm your agreement to the disclosure of the information contained in the application and your confirmation of its accuracy.
Signature: Name (in print): Date:
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