Fmcs Form R-43 - Request For Arbitration Panel Page 2
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1
2REQUEST FOR ARBITRATION PANEL
SPECIAL REQUIREMENTS
Note: ALL requests on this page must be “CERTIFIED” as jointly agreed AND signed below.
Requests on this page will NOT be honored without proper certification.
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Select panel from Nationwide
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EXPEDITED ARBITRATION under FMCS Procedures
(See FMCS Arbitration Policies and Procedures, Subpart D, Section 1404.17 for specific requirements for Expedited
Arbitration.)
ORGANIZATIONS or CERTIFICATIONS:
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Attorney
AAA (American Arbitration Assoc.)
Industrial Engineer
NAA (National Academy of Arbitrators)
SPECIALIZATIONS:
Industry Specialization: _________________________________________________________
Issue Specialization:
_________________________________________________________
ADDITIONAL REQUIREMENTS: (For example, geographical restrictions, exclusions of arbitrators)
_____________________________________________________________________________________
_____________________________________________________________________________________
A panel will be sent based upon the request of a single party. If “Special Requirements” are listed or “Expedited
Arbitration” is requested, you MUST certify that all parties jointly agree to these requests. This also applies to additional panel
requests. If your contract contains these “Special Requirements,” including “Expedited Arbitration,” submit a copy of the
relevant contract language only. A submission of a panel should not be construed as anything more than compliance with a
request and does not reflect on the substance or arbitrability of the issue(s) in dispute.
I certify that the above is jointly agreed.
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Signature:_________________________________________
On behalf of:
Union
Employer
NOTICE TO CUSTOMERS MAKING PAYMENT BY CHECK
Authorization to Convert Your Check: If you send us a check to make your payment, your check will be converted into
an electronic fund transfer.
“Electronic fund transfer” is the term used to refer to the process in which we
electronically instruct your financial institution to transfer funds from your account to our account, rather than
processing your check. By sending your completed, signed check to us, you authorize us to scan your check and to use
the account information from your check to make an electronic fund transfer from your account for the same amount
as the check. If the electronic fund transfer cannot be processed for technical reasons, you authorize us to process your
original check.
Insufficient Funds: The electronic fund transfer from your account will usually occur within 24 hours, which is faster
than a check is normally processed. Therefore, make sure there are sufficient funds available in your checking account
when you send us your check. If the electronic fund transfer cannot be completed because of insufficient funds, we will
not resubmit the check information for electronic fund transfer. Your bank may charge you a fee for insufficient funds.
Transaction Information: The electronic fund transfer from your account will be on the account statement you received
from your financial institution. However, the transfer may be in a different place on your statement than the place
where your checks normally appear. For example, it may appear under “other withdrawals” or “other transactions.”
You will not receive your original check back from your financial institution. For security reasons, we will destroy your
original check, but we will keep a copy of the check for record keeping purposes.
Your Rights: You should contact your financial institution immediately if you believe that the electronic fund transfer
reported on your account statement was not properly authorized or is otherwise incorrect. Consumers have protections
under a Federal law called the Electronic Fund Transfer Act for an unauthorized or incorrect electronic fund transfer.
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