Fmcs Form R 43 – Fill Out and Use This PDF

FMCS Form R-43			Form Approved
Rev. February 2003	FEDERAL MEDIATION AND CONCILIATION SERVICE		OMB No. 3076-0002
	WASHINGTON, DC 20427		Expires 09-30-2014
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: www.fmcs.gov

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.)
5. Type of Issue:_________________________________________________________________________________________________
6. 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.
7. Type of Industry: □ Private Sector			□ State or Local Government			□ Federal Government
8. Payment Options: $50.00 per panel				OR	$30.00 IF FILED AT WWW.FMCS.GOV
□ 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.

REQUEST FOR ARBITRATION PANEL

SPECIAL REQUIREMENTS

(See FMCS Arbitration Policies and Procedures, Subpart D, Section 1404.17 for specific requirements for Expedited Arbitration.)

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.

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.