Fmcs Form R-43 - Request For Arbitration Panel

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FMCS Form R-43

Form Approved

FEDERAL MEDIATION AND CONCILIATION SERVICE

Rev. February 2003

OMB No. 3076-0002

Expires 09-30-2014

WASHINGTON, DC 20427

Phone: (202) 606-5111

REQUEST FOR ARBITRATION PANEL

Fax requests with payment information to (202) 606-3749

DATE:____________________________

If you fax, do not forward a hard copy.

You may file this form electronically at:

1. EMPLOYER

Company Name:_____________________________________________________________________________________

Representative Name: (Last)_________________________(First)___________________________________(Initial)____

Street:_____________________________________________________________________________________________

City: __________________________________________State: _______________ Zip Code: ______________________

Phone: ____________________________________________Fax:_____________________________________________

E-mail:_________________________________________________________

2. UNION

Union Name:______________________________________________________________________Local #____________

Representative Name: (Last)_________________________(First)___________________________________(Initial)____

Street:_____________________________________________________________________________________________

City: __________________________________________State: _______________ Zip Code: ______________________

Phone: ____________________________________________Fax:_____________________________________________

E-mail:_________________________________________________________

3. Site of Dispute: City: _______________________________________ State: ____________ Zip Code:*______________________

*Required for Metropolitan Selection

4. Select the panel of arbitrators from below or see “Special Requirements” on page 2.

□

Regional

Sub-Regional

Metropolitan (125 mile radius from site of dispute. May cross state boundaries.)

Type of Issue

:_________________________________________________________________________________________________

Panel Size

: ______

A panel of (7) names is usually provided. If this is a unilateral request, you must attach your relevant contract language

which specifies a different number or “certify” on Page 2 that both parties have agreed to the number specified.

□

Private Sector

State or Local Government

Federal Government

7. Type of Industry:

8. P

ayment Options: $50.00 per panel

$30.00 IF FILED AT

□

Check or Money Order Name on Account: _____________________________________

Type: Personal Checking

□

(SEE DISCLOSURE STATEMENT ON PAGE TWO IF PAYMENT IS BY CHECK.)

Business Checking

□ ABA Routing Number: _ _ _ _ _ _ _ _ _

□ Check to split payment evenly

□

VISA □ MASTERCARD

AMERICAN EXPRESS

□ DISCOVER

□ PREPAID ACCOUNT

□

Name (1): ________________________________ Paid by:

Union

Employer

Amount: _____________________

Card Number: _____________________________________________________ Expires: Month: ____________ Year: ____________

□

Name (2): ________________________________ Paid by:

Union

Employer

Amount: _____________________

Card Number: _____________________________________________________ Expires: Month: _____________Year: ___________

ALC for Federal Agencies: ALC #__________________________________________ Prepayment #_________________

9. Signatures:

Employer: _____________________________________ Union: ___________________________________________

PAPERWORK REDUCTION ACT NOTICE: The estimated burden associated with this collection of information is 10 minutes per respondent. Comments concerning

the accuracy of this burden estimate and suggestions for reducing this burden should be sent to the Office of General Counsel, Federal Mediation and Conciliation Service,

2100 K Street, NW, Washington, DC 20427 or the Paperwork Reduction Project 3076-0002, Office of Management and Budget, Washington, DC 20503.