Arbitrator Disclosure Checklist
Please consult Canon II of the Code of Ethics for Arbitrators in Commercial Disputes regarding your obligation to disclose any interest or relationship likely to affect impartiality or which might create an appearance of partiality.  You have a continuing obligation to update this form whenever you recall or discover any information that should be disclosed.
Please explain any “Yes” answers in the space provided below.
Note: The completed form will be available to the parties to this dispute.
THE DISPUTE
Prior knowledge of the dispute	Yes   No 
Financial interest in the outcome	Yes   No 
Personal interest in the outcome 	Yes   No  
PAST OR CURRENT RELATIONSHIPS
Financial, business, professional, or personal relationships between you and: 
  a party to this proceeding	Yes   No 
  a lawyer representing a party to this proceeding 	Yes   No 
  the law firm of a lawyer in this proceeding	Yes   No 
  a co-arbitrator in this proceeding	Yes   No 
  an individual whom you have been told will be witness	Yes   No 
Relationships between your family or household members and:
  a party to this proceeding	Yes   No 
  a lawyer representing a party to this proceeding	Yes   No 
  the law firm of a lawyer in  this proceeding	Yes   No 
  a co-arbitrator in this proceeding	Yes   No 
  an individual whom you have been told will be a witness	Yes   No 
Relationships between your current employer, partners, or professional or business associates and: 
  a party to this proceeding	Yes   No 
  a lawyer representing a party to this proceeding	Yes   No 
  the law firm of a lawyer in this proceeding	Yes   No 
  a co-arbitrator in this proceeding	Yes   No 
  an individual whom you have been told will be a witness	Yes   No 
PROSPECTIVE RELATIONSHIPS
Discussions with a party about prospective employment or compensated service as a dispute resolution neutral	   Yes   No 
Arrangements with a party concerning prospective employment or other compensated service as a dispute resolution neutral 	  Yes   No 
ADDITIONAL REQUIRED DISCLOSURES
Additional disclosures required by an agreement between the parties	Yes   No 
Additional disclosures required by applicable state or federal law	Yes   No 
OTHER
Additional factors that might create an actual or apparent conflict of interest	Yes   No 
Conditions that might impede my ability to serve	 Yes   No 
DETAILS REGARDING “YES” ANSWERS TO ANY OF THE QUESTIONS ABOVE

	

I hereby certify that, to the best of my knowledge, the responses provided above are complete and accurate.

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Arbitrator