INTERNATIONAL CENTRE FOR DISPUTE RESOLUTION The International Division of the American Arbitration Association SUBMISSION TO DISPUTE RESOLUTION The named parties hereby submit the following dispute for resolution, under the rules of the International Centre for Dispute Resolution. International Dispute Resolution Procedures Rules Selected: Commercial Arbitration Rules and Mediation Procedures (AAA) Procedures for Cases under the UNCITRAL Arbitration Rules Other (please specify) Binding Arbitration Early Neutral Evaluation Fact-Finding Mediation Mini-Trial Procedure Selected: 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 Respondent Place of Hearing: We agree that, if arbitration is selected, we will abide by and perform any award rendered hereunder and that a judgment may be entered on the award. To be completed and signed by all parties Name of Party Name of Party Address Address City, State/Province, Country, Post Code City, State/Province, Country, Post Code Telephone Telephone Facsimile Facsimile Name of Party’s Attorney or Representative Name of Party’s Attorney or Representative Name of Firm (if applicable) Name of Firm (if applicable) Address Address City, State/Province, Country, Post Code City, State/Province, Country, Post Code Telephone Telephone Facsimile Signed† (may be signed by a representative) Title Facsimile Signed† (may be signed by a representative) 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, Suite 100, 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. American LegalNet, Inc. www.FormsWorkFlow.com