RECONCILIATION FORM

Step 1 of 3

I, the undersigned (Claimant):

Details of Claimant (*) :

Name *

First

Middle

Last

Nationality *

Email *

Phone or Mobile *

Phone or Mobile | Alternative

Fax

P.O Box

Website / URL

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Claimant Representative

(If any Legal Representative is available, the POA must be attached along with the Case statement).

Name

First

Middle

Last

Nationality

Phone or Mobile

Phone or Mobile | Alternative

Fax

P.O Box

Website / URL

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

I request to file a Reconciliation case against the Respondent(s):

Respondent Details (*):

Name

First

Middle

Last

Nationality

Phone or Mobile

Phone or Mobile | Alternative

Fax

P.O Fax

Website / URL

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Respondent Representative

(if there is any Respondent Representative, the POA must be attached along with the Statement of Claim)

Name

First

Middle

Last

Nationality

Phone or Mobile

Phone or Mobile | Alternative

Fax

P.O Box

Website / URL

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Regarding a dispute against the Respondent(s)

Dispute Details

Summary: Create an option to attach the Statement of Claim along with the documents of arguments.

File Upload

I apologize to mandate IICRA to appoint the Reconciler (s), thus I hereby nominate a Reconciler as follows:

(Or) IICRA will automatically appoint the Reconciler (s) to settle the Dispute in case Claimant unable to appoint him in the specific time as per IICRA Rules Article (43) under Reconciliation procedure.

Arbitrator Details

Name

First

Middle

Last

Nationality

Phone or Mobile

Phone or Mobile | Alternative

Fax

P.O Box

Website / URL

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Signature

Based on the above, I request IICRA to take all necessary measures to settle the dispute in accordance with IICRA Arbitration Rules, primarily Article No: 11 regarding the Mandatory Law (Sharia Principles).

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