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  1. 1. INTERNATIONAL CENTRE FOR DISPUTE RESOLUTION The International Division of the American Arbitration Association SUBMISSION TO DISPUTE RESOLUTIONThe named parties hereby submit the following dispute for resolution, under the rules of the International Centre for DisputeResolution.Rules Selected: International Dispute Resolution Procedures Commercial Arbitration Rules and Mediation Procedures (AAA) Procedures for Cases under the UNCITRAL Arbitration Rules Other (please specify)Procedure Selected: Binding Arbitration Early Neutral Evaluation Fact-Finding Mediation Mini-Trial Other (please specify)Nature of Dispute (attach additional sheets if necessary):Amount of Monetary Claim or Nature of Non-Monetary Claim:Type of Business: Claimant RespondentPlace of Hearing:We agree that, if arbitration is selected, we will abide by and perform any award rendered hereunder and that a judgment may beentered on the award. To be completed and signed by all partiesName of Party Name of PartyAddress AddressCity, State/Province, Country, Post Code City, State/Province, Country, Post CodeTelephone Facsimile Telephone FacsimileName of Party’s Attorney or Representative Name of Party’s Attorney or RepresentativeName of Firm (if applicable) Name of Firm (if applicable)Address AddressCity, State/Province, Country, Post Code City, State/Province, Country, Post CodeTelephone Facsimile Telephone FacsimileSigned† (may be signed by a representative) Signed† (may be signed by a representative)Title Date Title Date † Signatures of all parties are required.Please file two signed copies and the non-refundable filing fee with the ICDR at Case Filing Services, 1101 Laurel Oak Road, Suite100, Voorhess, NJ 08043 email: casefiling@adr.org.For additional information, please contact us at 1.888.855.9575 or +1 212 484 4181 or visit our website at www.icdr.org.

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