PEER INTERVIEW - Mediation - Chartered Institute of Arbitrators

PEER INTERVIEW - MediationREGISTRATION FORMPlease complete all sections in BLOCK CAPITALS and return your completed form to:CIArb Education & Training, Chartered Institute of Arbitrators, International Arbitration and Mediation Centre,12 Bloomsbury Square, London, WC1A 2LPTel: +44 (0)20 7421 7439 Fax: +44 (0)20 7404 4023 Email: education@ciarb.orgPERSONAL DETAILSSurname:Suffix:First Name:Title:CIArb Membership Number: Gender: Male FemaleAddress:Postcode:Tel:Country:Email:Please indicate how would you like to be contacted: Phone Letter EmailFELLOWSHIP REQUIREMENTSPlease tick the appropriate box(s) to indicate which route you have passed through to get to the Peer Interviewstage. (Please provide supporting documentation)Route 1 Route 2 Route 3 Route 4Other route. Please provide further details.AVAILABILITYPlease tick the appropriate box(s) to indicate your preferable months for the Peer Interview.JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberJanuary 2009

FEESThe correct fee must be submitted with the registration form in order for the registration to be processed.Debit / Credit CardPlease debit my: Visa Mastercard Maestro / SwitchAmount: Issue Number: Valid From: Expiry Date:Name on Card:Card Number:Security Number:Signature:Cheque / Bank DraftPlease find enclosed a cheque / bank draft made payable to ‘CIArb’ for the amount: _________________________Bank TransferIf payment is made by bank transfer, this should be made payable to the CIArb, HSBC Bank, 31 Holborn, London,ECIN 2HR, United Kingdom. Sort Code: 40 05 03, Account Number: 31288784, International Bank Account Number(IBAN): GB38MIDL40050331288784, Branch Identifier Code (BIC): MIDLGB2115N.APPLICANT’S SIGNATUREI certify that the information provided is accurate to the best of my knowledge. I have read and accept the PeerInterview Guidance Sheet for candidates.Signature:Date:CHECKLISTPlease check to ensure the following have been carried out before the form is sent to CIArb:All sections of the form have been completed.You have read the Peer Interview Guidance Sheet for candidates.You have provided the relevant supporting documentation (if applicable).The correct fee is enclosed.You have signed and dated the form.January 2009