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Please provide the following information in connection with your dispute with (“Responding Party”), as submitted by you or the organization that you represent (“Initiating Party” and together with the Responding Party, the “Parties”):

Name of the Initiating Party:

Address of the Initiating Party:

Telephone Number of Initiating Party:

E-mail Address of Initiating Party:

Name of Responding Party:

Address of Responding Party:

E-mail Address of Responding Party:

The Initiating Party previously agreed to the Terms and Conditions (“Terms”). The Terms contain a valid and binding arbitration clause for the resolution of disputes, a copy of which is attached hereto as Exhibit A The Parties are in dispute as to the following issue(s):

As the Parties cannot agree as to the resolution of the subject dispute, the Initiating Party hereby demands that the Responding Party submit to arbitration pursuant to the rules and procedures set forth by either the American Arbitration Association (“AAA”) or the Judicial Arbitration and Mediation Services, Inc. (“JAMS”), as selected by the Initiating Party.

The Initiating Party is claiming the following damages:

Total Damages Claimed $ ___________________

In filing this Demand for Arbitration (“Demand”), the Initiating Party certifies the following:

He/she/it has provided the Responding Party with a copy of this Demand by both e-mail and by certified mail, return receipt requested.

So demanded and certified, this _____ day of ________________, 20____.

Initiating Party

Sworn to and subscribed before me, this _____ day of __________________, 20____.

Notary Public.

(PLEASE NOTE: Notarization is required for original and mailed copies only. Notarization is not required to file or serve this Demand via e-mail)