Organisation mondiale de la propriéTÉ intellectuelle centre d’arbitrage et de médiation de l’ompi




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Annex B

ORGANISATION MONDIALE


DE LA PROPRIÉTÉ INTELLECTUELLE

Centre d’arbitrage et de médiation de l’OMPI






WORLD INTELLECTUAL

PROPERTY ORGANIZATION




WIPO Arbitration and Mediation Center




STATEMENT OF ACCEPTANCE AND DECLARATION OF IMPARTIALITY AND INDEPENDENCE



Case Number: [Case Number]

I, the undersigned, [Name of Panel]


[ ] hereby declare that I accept to serve as a Panelist under the .IR Domain Name Dispute Resolution Policy and the Rules for .IR Domain Name Dispute Resolution Policy (the Rules), both approved by the IRNIC, the .IR domain name registration authority and the WIPO Arbitration and Mediation Center’s Supplemental Rules for .IR Domain Name Dispute Resolution Policy (the Supplemental Rules). By making this declaration, I confirm that I have familiarized myself with the principles, standards, requirements and fees set out in the aforementioned instruments and that I am available to serve as a Panelist in accordance therewith. I further declare that, by accepting to serve as a Panelist in this case, I shall execute my responsibilities honestly, fairly and within the time periods required by the Rules and Supplemental Rules.
Please check the appropriate box below, taking into consideration, inter alia, whether there exists any past or present relationship, direct or indirect, with either of the parties, whether financial, professional or of another kind and whether the nature of any such relationship is such that disclosure is called for. [Any doubt should be resolved in favor of disclosure].
[ ] I am independent of each of the parties. To the best of my knowledge and belief, there are no facts or circumstances, past or present, or that could arise in the foreseeable future, that need be disclosed as they might be of a such a nature as to call in to question my independence in the eyes of one or both of the parties.
[ ] I am independent of each of the parties. However, I wish to disclose the circumstances described in the attachment hereto (attach separate sheet) as they might be of such a nature as to call in to question my independence in the eyes of one or both of the parties.
[ ] I hereby declare that I decline to serve as a Panelist in the present case. (Disclosure of the reasons for declining to accept the appointment should be made on a separate sheet and attached hereto.)

Place: ___________________ Signature:_____________________


Date: ______________

34, chemin des Colombettes, 1211 GENÈVE 20 (SUISSE)  (41-22) 338 9111 Fax (41-22) 740 3700 e-mail: domain.disputes@wipo.int

Internet: http://www.arbiter.wipo.int Banque: Crédit Suisse, Genève, compte OMPI Nº 48 7080-81 Chèques postaux: OMPI Nº 12-5000-8, Genève




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