File n°:............

DECLARATION OF ACCEPTANCE , AVAILABILITY AND INDEPENDENCE BY THE ARBITRATOR

I the undersigned,
Surname: .......................................................First name: ............................................

1. ACCEPTANCE
O Accept the arbitral mission in accordance with the CEPANI Rule 2013.

2. AVAILABILITY
O Confirm, on the basis of the information presently available to me, that I can
devote the time necessary to conduct this arbitration diligently, efficiently and in
accordance with the time limits in the Rules.

3. INDEPENDENCE
O declare that I am fully independent of:
O the parties
O their legal counsel
O draw CEPANI's attention to the following facts and circumstances that could lead
any of the parties to doubt my independence (use a separate sheet if
necessary).

* * *

O declare that I shall abide by the "Rules of good conduct for procedures requiring
the intervention of CEPANI" enclosed as Annex II to the CEPANI Arbitration
Rules.

Done at .............................., on ......................................

Signature:
Tick the corresponding boxes