1. PARTICULARS OF APPLICANT

Your Full Name (Surname First) *

Email address *

Telephone *

Country* City*
AfghanistanFinlandAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaNorfolk IslandAntigua and BarbudaArgentinaArmeniaArubaCocos (Keeling) IslandsAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State of boliviaBosnia and HerzegovinaBotswanaSvalbard and Jan MayenBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonUnited StatesCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCongo, The Democratic Republic of the CongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaSouth Georgia and the South Sandwich IslandsFaroe IslandsFijiFranceFrench GuianaFrench PolynesiaReunionGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaSaint MartinGuamGuatemalaUnited KingdomGuineaGuinea-BissauGuyanaHaitiHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic of Persian GulfIraqIrelandIsraelItalyJamaicaJapanJordanRussiaKenyaKiribatiKorea, Democratic People's Republic of KoreaKorea, Republic of South KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMexicoMicronesia, Federated States of MicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaPitcairnNicaraguaNigerNigeriaNiueNorthern Mariana IslandsOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRwandaSaint Helena, Ascension and Tristan Da CunhaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic of TanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic of VenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaYemenZambiaZimbabwe

Postal Code* Fax

Add Nationality

Nationality (Identity Document/Passport No)*

Attach Copy

Primary Occupation*

Name of Firm (if applicable)

Mailing address

2. EDUCATION

a. Level of Academic Qualification*

Add Row

Degree or Certificate

Year Awarded

Institution Name

b. Mediation Training*

Add Row

Course

Year Awarded

Institution Name

c. Other training in dispute resolution*

Add Row

Course

Year Awarded

Institution Name

* Attach proof of qualification and training. (If you have been involved in such training as a facilitator, trainer or instructor, give a description of your role.)

c) Number of years you have acted as an Mediator?

Please attach a brief resume/curriculum vitae/profile

d) Are you a certified/accredited Mediator or listed in the panel of any other arbitral/mediation institution?
YESNO

e) Whether currently mediation is your primary (full-time) practice?
YESNO

(Please attach to the application recommendation by two references who attest to your mediation experience. A certified/notarised Identification Document for the Referee must be attached.)

4. OTHER INFORMATION

a) Outline any other relevant experience or provide any other information which supports your application (including where your mediation experience involves disputes of an international character)..

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

5. DECLARATION

I understand the Nairobi Centre for International Arbitration does not provide employment for any mediator. I also understand the decision to nominate or appoint a mediator or mediators to any mediation referred to Nairobi Centre for International Arbitration is within the exclusive discretion of the Nairobi Centre for International Arbitration.

  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 NCIA Mediator Panel Status.

6. UNDERTAKING

  I agree, if accredited to NCIA Mediator Panel Status, to be bound by the terms and conditions applicable to NCIA Mediator Panel Status and to comply with the Mediator Panel Status Standard, the NCIA Code of Conduct for Arbitrators, Nairobi Centre for International Arbitration (Arbitration) Rules, 2015 or there amendments or alterations from time to time and any other professional or legal requirement to which I am subject.

7. CONSENT FOR USE OF PERSONAL INFORMATION

 I consent to NCIA using my personal information that I have provided in this application for the processing of my application, background and reference checks, for purposes of future appointments (if any) in any mediations handled by NCIA. Should my application by successful, I consent to NCIA’s provision of my personal information to third parties when requested to do so in connection with such purposes.