Binding Arbitration Consent Form {10769}

Revised 07/26/2005, CN 10769 Binding Arbitration Program Consent Form County Caption of the Case: V. Docket No: 1. I acknowledge receipt of a copy of the Voluntary Binding Arbitration Program Guidelines which I have read and understand. I consent to having the above captioned case submitted to the panel of and I agree to accept and to be bound irrevocably by the panel's decision. 3. I understand that the panel's decision is binding and that my case is being dismissed with prejudice as soon as I execute this form. 4. I understand that I waive my rights to trial by jury and to all appeals. Check one: I understand that the award of the panel will not be less than $ nor more than $ without interest. I understand that there is no "high/low" range and that the award, if any, is in the panel's sole discretion, without interest, unless agreed to in the application and Dated: Plaintiff's Attorney Defendant222s Attorney Defendant American LegalNet, Inc. www.FormsWorkFlow.com