CEPINA

REQUEST FOR APPEAL

Here you can download the model for the Request for Appeal

2. Identity of the representative authorized to act for the Complainant in appeal

(optional):

3.1. Electronic communication by e-mail via the Internet

E-mail address:..............................................................................

3.2. Communications containing Hard copy (make your choice)

O By post
Address:.......................................................................................

O By Fax
Fax number...................................................................................

3.3. Person to be contacted and address information:

Name:............................................................................................

Function:.......................................................................................

Address:........................................................................................

Telephone:.....................................................................................

Fax:...............................................................................................

E-mail:...........................................................................................

4. Address information of the Respondent in appeal

4.1.

Name:............................................................................................

Person to be contacted:.................................................................

Function:.......................................................................................

Address:........................................................................................

Telephone:.....................................................................................

Fax:...............................................................................................

E-mail:...........................................................................................

4.2. Representative of the Respondent in appeal

Name:............................................................................................

Function:.......................................................................................

Address:........................................................................................

Telephone:.....................................................................................

Fax:...............................................................................................

E-mail:...........................................................................................

5. Domain name(s) that is (are) the subject of the Complaint.

(maximum 5.000 words).
...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ......................................................................................................

...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ...................................................................................................... ......................................................................................................

The Complainant confirms that the costs, mentioned in Article 21 of the CEPANI rules for domain name dispute resolution are paid and provides the proof of payment on account 210-0076085-89, IBAN: BE 45 2100 0760 8589.

Invoice data:
Name: .....................................................................................
Address: ..................................................................................
TVA-number: ............................................................................

11. Statement
"The Complainant in appeal agrees that its claims and remedies concerning the registration of the domain name, the dispute or the dispute’s resolution shall be directed solely against the Domain name holder and expressly waives all such claims against (a) CEPANI and its directors or employees and (b) the Third-Party Deciders, except in the case of deliberate wrongdoing.

The Complainant in appeal certifies that the information contained in this Complaint is to the best of his knowledge complete and accurate."

Date	Name and signature of The Complainant or representative

10. Costs

9. Other legal proceedings, commenced or terminated, which relate to any of the domain name(s)

8. Specification, in accordance with the Policy, of the remedies sought

7. Description of the means invoked

6. Number of the decision against which the appeal is made and the identity of the Third-Party Decider

3. Preferred method for communications directed to the Complainant in appeal

Name:............................................................................................

Function:.......................................................................................

Address:........................................................................................

Telephone:.....................................................................................

Fax:...............................................................................................

E-mail:...........................................................................................

(Representatives must have special power of attorney)

Name:............................................................................................

Address:........................................................................................

Telephone:.....................................................................................

Fax:...............................................................................................

E-mail:...........................................................................................

REQUEST FOR APPEAL
This complaint is submitted in view of a decision of a panel of three Third-Party Deciders, according to the CEPANI rules for domain name dispute resolution and the dispute resolution policy of DNS, incorporated in its General Conditions.

1. Identity of the Complainant in appeal