IDA Securities Dispute Resolution Program

Applying for (check one):

_________ Arbitration

_________ Mediation

Return the completed form with the application fee of $214.00 ($200 plus GST) to:

British Columbia International Commercial Arbitration Centre
#500-1311 Howe Stree
Vancouver, BC
V6Z 2P3

Name of Client ("Claimant"):

_____________________________________________

Name of Representative or Legal Counsel (if any):

______________________________________
Address:
__________________________________________________________ __________________________________________________________ __________________________________________________________

Telephone: Home: __________________ Office: ____________

Fax: _______________________

Name of Brokerage Firm ("Respondent"): ____________________________________

Name of Contact Person at the Firm: _________________________________________

Address:__________________________________________________________ __________________________________________________________ _________________________________________________________

Telephone:______________________________ Fax: _______________________

When did the dispute originate/occur?_____________________________________

How much money is in dispute? _________________________________________

What steps have you taken to try to resolve the dispute with the brokerage firm? (Please attach documentation, copies of correspondence etc.)

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Describe the nature of your dispute (use additional pages as required):

____________________________________________________________________

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I request and agree that the above described matter be submitted to binding arbitration pursuant to the Rules of Procedure for Domestic Commercial Arbitration of the British Columbia International Commercial Arbitration Centre as modified by the terms of the IDA Securities Arbitration Program. I acknowledge that by doing so I restrict my rights to pursue this matter through the Courts.

________________________
Date

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Name (please print)

________________________
Signature

OR

I request mediation of the above described matter in an attempt to negotiate a settlement of the dispute with the brokerage firm.

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Date

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Name (please print)

________________________
Signature