ICC International Court of Arbitration

33-43 avenue du Président Wilson

75116 Paris

France

FAO: [Insert name of contact at the ICC or the Secretariat of the ICC]

[Insert date]

Dear [ICC Court],

ICC Arbitration No: [reference] [Claimant] v. [Respondent] – request for the appointment of the [sole arbitrator OR president of the tribunal]

The Parties have been unable to reach agreement upon the identity of [the sole arbitrator OR the president of the arbitral tribunal] for the above-referenced proceedings.

In accordance with [article 12(3) of the ICC Arbitration Rules OR article 12(5) of the ICC Arbitration Rules OR , the Claimant hereby respectfully requests the ICC Court to appoint the sole arbitrator OR president].

Yours faithfully,

[Claimant's counsel]

cc [Respondent's Counsel]

[Address]