STATEMENT OF ACCEPTANCE  
                                                                                                                       AND DECLARATION OF INDEPENDENCE AND IMPARTIALITY 
                                                               
                                                                                                                                                                                                                                       
                                                                                     Case Number:                                                                                                                         
                                                                                      
                                                                                     I , the Undersigned,  
                                                                                                                                                                                                                                       
                                                                                     Last Name:                                                                                                                           
                                                                                                                                                                                                                                       
                                                                                     First Name:                                                                                                                          
                                                                                      
                                                              (please tick the relevant boxes) 
                                                               
                                                       A. Acceptance with Declaration 
                                                               
                                                                                                        Hereby declare that I accept to serve as arbitrator in accordance with the QSAT General 
                                                                                                        Secretariat’s letter of appointment dated  …../…../……,  and under the Arbitration Rules 
                                                                                                        of  Qatar Sports Arbitration Tribunal and all relevant rules and regulations applicable 
                                                                                                        therein “ the Rules”. 
                                                                                                         
                                                              By making this statement of acceptance, I confirm that I have reviewed, and I am familiar with “ 
                                                              the Rules” and therefore declare that:  
                                                               
                                                                                                        I am available as required to complete the arbitration proceedings expeditiously. 
                                                                                                         
                                                                                                        I shall exercise my functions personally to the best of my knowledge in order to secure a 
                                                                                                        professional  and  effective  resolution  of  the  dispute  and  execute  my  responsibilities 
                                                                                                        faithfully and fairly within the time periods determined by “the Rules”. 
                                                                                                         
                                                                                                        I am impartial and independent of each of the parties and intend to remain so.  
                                                                                                        To the best of my knowledge and belief, there are no facts, circumstances, past or 
                                                                                                        present or relationships of any kind that might be of such a nature as to give rise to any 
                                                                                                        justified doubts as to my independence or impartiality in the eyes of any of the parties. 
                                                                                        
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                                   I am impartial and independent of each of the parties and intend to remain so.  
                                   However, in consideration of Art. (8.2) of the Arbitration Rules of Qatar Sports Arbitration 
                                   Tribunal, I wish to disclose certain circumstances, facts, relationships described in the 
                                   attached sheet for the consideration of Qatar Sports Arbitration Tribunal  prior to the 
                                   confirmation of my appointment, which might be of such a nature likely to give rise to 
                                   any  justified  doubts  as  my  independence  or  impartiality  with  respect  to  any  of  the 
                                   parties. 
                                    
                                   I have a good command of the working languages of Qatar Sports Arbitration Tribunal.  
                                    (please check the appropriate circle below) 
                                                                    
                                            English               Arabic 
                                    
                                   I  have  read  and  agree  to  the  provisions  stipulated  and  the  rates  determined  in  the 
                                   Schedule of Arbitration  Costs being  the  Annex  (1)  to  the  Arbitration  Rules  of  Qatar 
                                   Sports Arbitration Tribunal and accept that my fees and expenses will be determined 
                                   exclusively by the Qatar Sports Arbitration Tribunal’s competent body on the basis of 
                                   this schedule. 
                             
                     B. Non-Acceptance 
                      
                                   I hereby declare that I decline to serve as arbitrator in this case. 
                                    
                                   1. If you tick in this field, please sign and date the form without filling any other section.  
                                        
                                   2. If you wish to disclose the reasons for your non-acceptance, please do so on a separate sheet 
                                       attached hereto. 
                                    
                              
               Date                        :      
                                                  
               Signature  : 
                              
                              
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