Mediation

To: The Japan Commercial Arbitration Association

1. Requesting party:

Full personal or corporate name
Address
Telephone number
Facsimile number
E-mail address

2. (If the requesting party is represented by an agent,)

Name
Address
Telephone number
Facsimile number
E-mail address

3. Person who is requested to be the party to mediation:

Full personal or corporate name
Address
(If known,)
　Telephone number
　Facsimile number
　E-mail address

4. Summary of the dispute and the desired outcome

5. If the parties have agreed to refer the dispute to mediation under these Rules, a copy of any such agreement.

6. If the party has the wishes as to the language to be used in the proceedings, such language.

As stated above, I hereby request for mediation under the international commercial mediation rules
(Attachments, if any):

(1) A power of attorney
(2) Mediation agreement

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　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　(Signature)　　　　　　　　　　　　　　

　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Attorney-at-law
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Attorney for the requesting party