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Notice of Request to Arbitrate
This Form Constitutes the Official Request to Arbitration under the DRB Arbitration Rules
Notice of Request to Arbitrate
Date
*
Claimant filing the Notice of Request to Arbitrate
*
Organization
Address
*
Phone
*
Fax
Email
*
Claimant's Counsel
*
Organization
Address
*
Phone
*
Fax
Email
*
Respondent - 1
*
Organization
Address
*
Phone
*
Fax
Email
*
Respondent's Counsel
*
Organization
Address
*
Phone
*
Fax
Email
*
Respondent - 2 (if applicable)
Organization
Address
Phone
Fax
Email
Respondent's Counsel
Organization
Address
Phone
Fax
Email
Respondent - 3 (if applicable)
Organization
Address
Phone
Fax
Email
Respondent's Counsel
Organization
Address
Phone
Fax
Email
1. Provide a Brief Description of the Matters in Dispute or a Statement of Claim including the name of the Final Agreement(s) and the section(s):
*
2. Where compensation is claimed, provide an estimate of amount claimed or the value of the issue in dispute:
3. Where the value cannot be estimated provide an explanation of the reason:
4. Provide a statement of what remedy the claimant is seeking:
5. State whether the parties have agreed to the Tribunal being comprised of:
*
one arbitrator
three arbitrators
have not yet agreed
6. Provide the name(s) of any agreed upon Arbitrator(s):
7. Provide the agreed upon qualifications of the Arbitrator(s):
8. Request for appointment of Arbitrator(s) by the Dispute Resolution Board:
*
No
Yes
State number of requested tribunal arbitrators:
one
three
9. Provide a statement of any variations or exclusions of the Rules to which the parties have agreed to in writing:
Please append the following: a) A statement of the specific provision of a Settlement Agreement or Settlement Legislation under which the dispute is referred to arbitration
b) A copy of any agreement between the parties to refer a dispute to arbitration
c) A copy of any contract related to the dispute
Signature
*
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