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ASI Application for Panel Arbitrator Membership

Name:_______________________________________________________

Address:_____________________________________________________

Business affiliation:_____________________________________________

Telephone number:_____________________________________________

Fax Number:__________________________________________________

Email Address:________________________________________________

Occupation:___________________________________________________

Business address:______________________________________________

Date of Birth:___________________________________________________

Education and Degrees:__________________________________________

Work Experience:_______________________________________________

Prior Arbitration Experience:_______________________________________

Requested Rates Per Session Or Hourly:_____________________________

Will Accept NAA Rates?__________________________________________

Availability?___________________________________________________

Business References:____________________________________________

Personal References:____________________________________________

Professional Associations:________________________________________

Trade Associations:______________________________________________

The undersigned authorizes Arbitration Services, Inc.  to contact all references, conduct a background check, both personal and financial, and understands that the $100 application fee is non-refundable.