HONG KONG MEDIATION SERVICES LIMITED

APPLICATION FOR MEDIATION SERVICE

[For Official use only: HKMSL Ref : ]

(i) THE APPLICANT(PARTY 1) NAMED BELOW HEREBY REQUESTS THE HONG KONG MEDIATION SERVICES LIMITED TO PROVIDE SERVICES FOR MEDIATION.

(ii) DETAILS OF PARTIES

PARTY 1: Claimant /Plaintiff/Applicant/ Petitioner /Defendant /Respondent in the issue
Name: ______/Organization:______
Address:______
______
Telephone:______
Fax:______
E-mail:______/ Legal representative, if applicable
Name:______
Company name:______
Address:______
______
Telephone:______
Fax:______
E-mail:______
PARTY 2:Claimant /Plaintiff/Applicant/ Petitioner /Defendant /Respondent in the issue
Name: ______/Organization:______
Address:______
______
Telephone:______
Fax:______
E-mail:______/ Legal representative, if applicable
Name:______
Company name:______
Address:______
______
Telephone:______
Fax:______
E-mail:______

(iii)High / District / Family Court / Tribunal Action No. (if any) ______

(iv)Brief self-explanatory statement of the nature of the issue and the quantum in issue (if any). (Use separate sheet or enclose pleadings / documents if you think necessary.)

______

(v) LANGUAGE in mediation：

□ Cantonese□ English□ Putonghua / Mandarin □ Other, please specify ______

(vi) Request : e.g. Please introduce to me (us) no more than 2 mediatorswith their quotations / Please introduce to me (us) one mediator (please list out your proposed term) / Please send a letter of invitation for mediation to the Party 2, etc.______

______

(vii) APPLICANT CONFIRMATION:

a. The personal data and documents provided by the Applicant is for the purpose of processing the mediation. In this connection, the data and documents so provided will be handled by or revealed to the following:

1.personnel of the Hong Kong Mediation Services Limited (“HKMSL”);

2.potential mediators/experts; and

3.mediator engaged by the Applicant.

b.The mediator and the HKMSL are not required to maintain any documents after mediation services.

c.The Applicant agrees to cooperate with the personnel of the HKMSL and the mediator by providing all relevant documents and information, when requested, including information that may be personal data, to enable such personnel of the HKMSL and the mediator to handle the issue;

d.The Applicant undertakes to keep all matters and information concerning and relating to the mediation confidential and will not disclose such matters and information to any person, other than the other party in the issue, the personnel of the HKMSL, and the mediator, save and to the extent required by the laws;

e.The Applicant agrees that HKMSL shall not be liable to any party for any act including act of negligence or omission and/or in relation to the conduct of the mediator arising out of or in connection with the mediation conducted;

f.The Applicant confirms that the information provided in this Application is true and accurate and on a voluntary basis and attach herewith a cheque in the sum of $500being payment of the HKMSL’s service charge.

Signature of Applicant

______

Name / Authorized person

HKID card no.

Company chop

Date

Notice Regarding the Personal Data (Privacy) Ordinance

(1) The personal data provided by means of this form will be used by the Hong Kong Mediation Services Limited for the following purposes:

(a) Processing the mediation service.

(b) Communication in the normal course and in case of emergencies.

(2) The provision of personal data by means of this form is voluntary. However, if insufficient information is provided, the application / request may be delayed or not be considered or processed.

(3) Applicant will have a right to request access to or the correction of his / her/ their personal data as stated in this form in accordance with Sections 18 and 22 and Principle 6 of Schedule 1 to the Personal Data (Privacy) Ordinance.

(4) Enquiries concerning the personal data collected by means of this form including the request for access and correction, should be addressed to Hong Kong Mediation Services Limited at 28400789 (Tel) or 25238127 (Fax).

1