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CIAC Form No.

001
(Revised January 2006)
Republic of the Philippines
Department of Trade and Industry
Construction Industry Authority of the Philippines
CONSTRUCTION INDUSTRY ARBITRATION COMMISSION

REQUEST FOR ARBITRATION


I. The Parties
CLAIMANT

NAME OF COMPANY : _______________________________________________________________________________________


AUTHORIZED
REPRESENTATIVE : ______________________________________________________________________________________
BUSINESS ADDRESS : ______________________________________________________________________________________
TELEPHONE NUMBER : ______________________________________________________________________________________

RESPONDENT
NAME OF COMPANY : _______________________________________________________________________________________
AUTHORIZED
REPRESENTATIVE : _______________________________________________________________________________________
BUSINESS ADDRESS : _______________________________________________________________________________________
TELEPHONE NUMBER : _______________________________________________________________________________________

II. Mode of Arbitration: [__] Sole Arbitrator [__] Arbitral Tribunal

III. Choice of Arbitrators: Maximum of Six [6] Nominees (By Order of Preference)

1. ______________________________________ 4. ___________________________________
2. ______________________________________ 5. ___________________________________
3. ______________________________________ 6. ___________________________________

IV. Agreement to Arbitrate

Is there an arbitration clause in the contract? [ __ ] Y [ __ ] N. If none, please accomplish the


AGREEMENT TOARBITRATE at the back hereof. In case of government contract, have all administrative
remedies been exhausted? [ __ ] Y [ __ ] N .

V. Sum in Dispute :___________________________________________________________ (_________________ )

VI. Documents Required : Please submit the following in: 5 copies if Tribunal / 3 copies if Sole Arbitrator

[ ] Complaint/Narration of Facts
[ ] Construction contract
[ ] Agreement to arbitrate
[ ] Documents establishing the circumstances of the case
[ ] In case of government contract, communications made with the highest authority for exhaustion
of administrative remedies.

_______________________________________
Date Filed : ____________________________ Signature of Authorized Representative
Case Number : ____________________________
Deposit Paid : ____________________________
O.R. No. : ____________________________ CTC No. : ____________________________
Date Issued : ____________________________ Issued at : _____________________________
Remarks : ____________________________ Issued at : _____________________________
________________________________________________ TIN : _____________________________

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