Page 1 of 1

Mediator Empanelment Application Form

This Application is for Empanelment as a Mediator with IIDRC. Empanelment is Subject to Eligibility Verification, Institutional Discretion, And Compliance with the Mediation Act, 2023.

SECTION 1 - PERSONAL DETAILS

Full Name

*

Date of Birth

*

Gender

*

Gender

A

Male

B

Female

C

Prefer Not to Say

Nationality

*

Phone Number

*

Email Id

*

Residential Address

*

City and State

*

LinkedIn Profile

*

Upload Recent Photograph

*

SECTION 2 - PROFESSIONAL EXPERIENCE

Primary Professional Background

*

Primary Professional Background

A

Legal Practitioner

B

Engineer

C

Finance Professional

D

Architect

E

Technology Professional

F

Psychologist

G

Infrastructure Professional

H

Other specialised professional

I

Retired Judge

Total Years of Professional Experience

*

Brief Description of Professional Experience Relevant to Dispute Resolution

*

SECTION 3 - ELIGIBILITY CATEGORY CONFIRMATION

Please Select the Eligibility Criterion You Qualify Under

*

Please Select the Eligibility Criterion You Qualify Under

A

Minimum 7 years of legal practice with substantive exposure to dispute resolution

B

Minimum 10 years of professional experience in a specialised field relevant to dispute resolution

C

Recognised expert in mediation or conciliation based on training, accreditation, or demonstrated proficiency

D

Retired Supreme Court Judge

E

Retired High Court Judge

Eligibility Declaration

*

Eligibility Declaration

I confirm that I satisfy at least one of the eligibility criteria prescribed for appointment as a Mediator

SECTION 4 - MEDIATION AND CONCILIATION TRAINING

Have you Completed any Mediation or Conciliation Training

*

Have you Completed any Mediation or Conciliation Training

A

Yes

B

No

SECTION 5 - PRIOR MEDIATOR EMPANELMENT

Are you Currently or Previously Empaneled with any Institution

*

Are you Currently or Previously Empaneled with any Institution

A

Yes

B

No

SECTION 6 - INDEPENDENCE AND IMPARTIALITY DISCLOSURE

Please disclose any circumstances that may give rise to doubts regarding independence or impartiality

*

SECTION 7 - FINAL DECLARATION AND CONSENT

Declaration

*

Declaration

I declare that the information provided is true and correct. I consent to verification by IIDRC and agree to comply with the Mediation Act, 2023, and IIDRC’s rules and ethical standards.

Digital Signature

*

Date of Submission

*