Form R-43 Form R-43 Request for Arbitration Services

FMCS Form R-43
Rev. February 2003

FEDERAL MEDIATION AND CONCILIATION SERVICE
WASHINGTON, DC 20427

Form Approved
OMB No. 3076-0002
Expires 12-31-2010

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: ______
7. Type of Industry:

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

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: _
□ VISA □ MASTERCARD

_

_ _ _ _ _ _ _
□ AMERICAN EXPRESS

□ Check to split payment evenly
□ DISCOVER

□ PREPAID ACCOUNT

Name (1): ________________________________ Paid by: □ Union
□ Employer
Amount: _____________________
Card Number: _____________________________________________________ Expires: Month: ____________ Year: ____________

□ Employer
Amount: _____________________
Name (2): ________________________________ Paid by: □ Union
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

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
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:

□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.
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.