สถาบันอนุญาโตตุลาการสำนักงานศาลยุติธรรมthai Arbitration Instutute

สถาบันอนุญาโตตุลาการสำนักงานศาลยุติธรรมTHAI ARBITRATION INSTUTUTE

Dear Arbitrator,

Regarding your nomination to be an arbitrator to in an arbitral proceeding under the auspices of the Thai Arbitration Institute, we, the Thai Arbitration Institute, would like to ask you to provide us with your personal information by filling the form attached hereto. In order to assure the integrity of the arbitral proceeding, we would like to ask you to disclose any and all facts that are or may be relevant to your impartiality or independence in discharging your duties as arbitrator. Such facts include any circumstances likely to give rise to justifiable doubts as to your impartiality or independence.

We will provide each party with a copy of your personal information as well as your disclosure, and will keep your information in our profile of arbitrators.

With regards to the particulars number 7-8, you may attach your brief curriculum vitae instead of filling the particulars. If you have previously provided such information to us in previous arbitral proceedings and the information is still accurate, you may refer to the information instead of filling the particular number 7-8.

We greatly appreciate your cooperation. If you have any inquiries, please do not hesitate to let us know.

The Thai Arbitration Institute (TAI)

Bangkok, Thailand

Case number (Black)……./………....

Arbitrator’s Personal Information

1. Name of Arbitrator

a. Title or Form of Address

(Mr., Ms., Miss., Mrs., Dr., etc)

b. First Name

c. Middle Name or Initial

d. Last Name

e. Suffix 1 (Jr., lll, etc.)

f. Suffix 2 (Esq., J.D., Ph.D., etc.)

2. Current Mailing Address

a. Firm Name

(If applicable, otherwise leave blank)

b. Street Address

c. Building/ Suite/Apt. Number

d. City, State or Province

Zip or Postal Code

e. Country

3. Phone Numbers (Please include area code.)

a. Business or Daytime Phone

b. Facsimile/ Fax

c. Home Phone

d. Other (Mobile, Pager, etc.)

4. E-Mail address

5. Employment information: (Please complete this section whether you work full-time, part-time, or on a consulting basis. If you are retired, indicate here and list your last employer in Question 8.

a. Current Position

b. Firm Name or Office Name

Use the same address in Question 2.

a. Street Address

b. Building/ Suite/Apt. Number

c. City, State or Province

Zip or Postal Code

d. Country

6. Honorarium Information

Account NameAccount No.

BankBranch Country

Type of Account Current A/C Saving A/COther ……………

Please use the information given in the case number (Black)……../…...
for the requirements number 7-8

I have attached my brief curriculum vitae for the requirements number 7-8

7. Educational History:

Start Date
mm/yyyy / End Date or Date Degree Awarded
mm/yyyy / School Name / Degree Awarded (If applicable)

8. Employment History / Work Experience:(A)

Start Date
mm/yyyy / End Date
mm/yyyy / Firm/Office Name / Description of Position and or Title / Indicate full or part-time

(B) Please specify fields which you have an experience or expertise.

(If you specify more than 3 fields, please give an example of experiences in (A) for each field)

Construction Contract International Trade and business Accounting

Intellectual Property Carriage of goods by sea Engineering

Taxation Banking and Finance Architecture

Tort International Investment Property

Natural Resources Family law and Succession Securities

Insurance Administrative law Labor law

Property appraisal Partnership / Companylaw Others………

Member of professional organization

Language Proficiency

English French German

Chinese Japanese Others………………

Signature

Date

Case number (Black) …………/………..

Arbitrator’s Disclosure Statement

With regard to my nomination as arbitrator in the above case, I hereby acknowledge the requirement under the Arbitration Rules of the Thai Arbitration Institute (TAI) that, as an arbitrator, I shall discharge my responsibilities with independence and impartiality. To assure the integrity of the arbitral proceeding and my performance as the arbitrator, I further acknowledge that I have an unconditional duty to disclose any and all facts or circumstances that may give rise to justifiable doubts as to my impartiality or independence. I shall also disclose such facts or circumstances that occur while I have not fully discharged my responsibilities as an arbitrator, without delay.

In accordance with the above requirement, I hereby make the following statements:

I possess the ability, experience and expertise necessary to discharge my responsibility as an arbitrator in the above case with impartiality and independence.

Do you or did you have an interest with the above case, or any of the following relationship with any party in the above case?

2.1 / Being an employee of a party, or its affiliates or subsidiaries. /  Yes /  No
2.2 / Being a partner, shareholder or stockholder of a party, or its affiliates or subsidiaries. /  Yes /  No
2.3 / Being a consultant, representative, attorney, lawyer or contractor of a party, or its affiliates or subsidiaries. /  Yes /  No
2.4 / Being engaged to provide advice or service, with or without remuneration, to a party, or its affiliates or subsidiaries, regardless of whether the relevant work has been carried out in my own name or in the name of the organization with which I have a relationship. /  Yes /  No
2.5 / Being a creditor, a debtor or an employer of a party, or its affiliates or subsidiaries. /  Yes /  No
2.6 / Being an expert appointed by a party, or its affiliates or subsidiaries. /  Yes /  No
2.7 / Having any interest relating to or involving with the above case. /  Yes /  No

(If your answer in any of the above questions is “yes”, please specify the relevant facts or circumstances.)

…………………………………………………………………………………

In addition to the above statement, do you have any further facts or circumstances that may give rise to justifiable doubts as to your impartiality or independence?

○Yes○No.

(If your answer is “yes”, please specify the facts or circumstances.)

…………………………………………………………………………………

I hereby affirm that any and all of the above statements are accurate. Throughout the arbitral proceeding, if there is any additional facts or circumstances that may give rise to justifiable doubts as to my impartiality or independence, I shall disclose the facts or circumstances without delay.

Signature

Date

Office of the Judiciary, Criminal Court Building 5th Floor., Rutchadapisek., Chutuchak Bangkok 10900 Thailand

Tel: (66) 0 2541 2298-9 Fax: (66) 0 2512 8434 e-mail: