Download:
pdf |
pdfFEDERAL MEDIATION AND CONCILIATION SERVICE
2100 K Street, NW
WASHINGTON, DC 20427
FMCS Form R-22
Revised January 2003
Form Approved
OMB No. 3076-0001
Expires 12-31-2010
(202) 606-5111
ARBITRATOR'S PERSONAL DATA QUESTIONNAIRE
I. BIOGRAPHICAL
E-Mail Address:
NAME: (Last, First, Middle)
Mr. ____ Ms. ____ Prof. ____ Dr. ____
CURRENT BUSINESS OR OCCUPATION:
BUSINESS ADDRESS 1:
Street:
BUSINESS ADDRESS 2: (or Home)
Street:
City, State, Zip:
City, State, Zip:
Phone:
(
)
Phone:
(
)
Fax:
(
)
Fax:
(
)
II. EDUCATION
INSTITUTION
MAJOR
DEGREE
YEAR
III. CERTIFICATIONS
PROFESSION
□
□
ISSUED BY
YEAR
ISSUED BY
YEAR
Attorney
Industrial Engineer
Others Relevant Certifications:
PROFESSION
IV. PROFESSIONAL MEMBERSHIPS:
Others Relevant Memberships:
□
National Academy of Arbitrators
□ American Arbitration Assn.
V. LABOR-MANAGEMENT RELATIONS EXPERIENCE (You MUST attach a resume that details your collective
bargaining experience.)
COMPANY/ORGANIZATION
POSITION
CITY/STATE
FROM (YR)
TO (YR)
PAPERWORK REDUCTION ACT NOTICE: The estimated burden associated with this collection of information is 30 minutes per respondent. Comments
concerning the accuracy of this burden estimate and suggestions for reducing this burden should be sent to the Director of Arbitration Services, Federal
Mediation and Conciliation Service (FMCS) 2100 K Street, N.W., Washington, DC 20427. Persons are not required to respond to this collection of information
unless it displays the currently valid OMB control number.
2
VI. Does your current employment or professional activity involve representation, advocacy, or participation in
(If you answered Yes,
decision making for labor organizations or employers in any capacity? □ No □ Yes
you MUST attach a full explanation of these activities.)
VII. PRESENT FEDERAL, STATE, COUNTY OR LOCAL GOVERNMENTAL POSITIONS, IF ANY (full-time, parttime, elected or appointed)
VIII. PERMANENT PANELS ON WHICH YOU CURRENTLY SERVE (e.g., USPS/NALC)
IX. ARBITRATION ROSTERS ON WHICH YOU CURRENTLY SERVE (e.g., NMB)
X. As an arbitrator, please indicate your experience by ISSUE and check the appropriate box for the number of cases
for each issue identified.
ISSUE
ABSENTEEISM
1-4
5 OR MORE
ISSUE
OFFICIAL TIME
AFFIRMATIVE ACTION
PAST PRACTICES
ARBITRABILITY
PENSION AND WELFARE PLANS
BARGAINING UNIT WORK
PENSION CLAIM (FED. STATUTE)
CONDUCT (OFF-DUTY/ PERSONAL)
PROMOTION
DEMOTION
RETIREMENT
DISCIPLINE (NON-DISCHARGE)
SAFETY/HEALTH CONDITIONS
DISCIPLINE (DISCHARGE)
SENIORITY
DISCRIMINATION
SEXUAL HARASSMENT
•
AGE
STRIKES, LOCKOUTS, WORK
STOPPAGES, SLOWDOWNS
•
DISABILITY
SUBCONTRACTING/CONTRACTING OUT
•
RACE
TENURE/REAPPOINTMENT
•
SEX
UNION SECURITY
•
RELIGION
•
NATIONAL ORIGIN
•
COST-OF-LIVING PAY
DRUG/ALCOHOL OFFENSES
•
HOLIDAY PAY
FRINGE BENEFITS
•
INCENTIVE PAY
•
BONUS
•
JOB CLASSIFICATION & RATES
•
HOLIDAYS
•
MERIT PAY
•
INSURANCE
•
OVERTIME PAY
•
LEAVE
•
SEVERANCE PAY
•
VACATION
•
VACATION PAY
WAGES
GRIEVANCE MEDIATION
WORK HRS/SCHEDS/ASSGNMTS.
HEALTH/HOSPITALIZATION
WORKING CONDITIONS/WORK ORDERS
HIRING PRACTICES
VIOLENCE OR THREATS
JOB PERFORMANCE
JOB POSTING/BIDDING
JURISDICTIONAL DISPUTE
LAYOFFS/BUMPING/RECALL
MANAGEMENT RIGHTS
1-4
5 0R MORE
3
XI. As an arbitrator, please indicate your experience by INDUSTRY and check the appropriate box for the number of
cases for each issue identified.
INDUSTRY
1-4 5 OR MORE
INDUSTRY
1-4
5 OR MORE
ADVERTISING
MACHINERY
AEROSPACE
MARITIME
AGRICULTURE
MEAT PACKING
AIRLINES
METAL FABRICATION
ALUMINUM
MINING
AUTOMOTIVE
NUCLEAR ENERGY
BAKERY
OFFICE WORKERS/CLERICAL
BANKING
ORGANIZATIONS
BEVERAGE
PACKAGING
BUILDING PRODUCTS
PAINT AND VARNISH
BREWERY
PETROLEUM/PETROCHEMICALS
BROADCASTING
PHARMACEUTICALS
CANNING
PLASTICS
CEMENT
PLUMBING
CHEMICALS
POLICE AND FIRE
CLOTHING
PRINTING AND PUBLISHING
COAL
PRISON GUARD
COMMUNICATIONS
PULP AND PAPER
CONSTRUCTION
RAILROADS
DAIRY
REAL ESTATE
DISTILLERY
REFRIGERATION/HVAC
EDUCATION
RESTAURANTS
ELECTRICAL EQUPMT./APPLIAN.
RETAIL STORES
ELECTRONICS
RUBBER/TIRE
ENTERTAINMENT/ARTS
SHIPBUILDING/DRY-DOCK
FEED & FERTILIZER
SPORTS
FOOD (MANU./PROC./SERVICE)
STEEL
FOUNDRY
STONE/QUARRY
FURNITURE
TEXTILE
GLASS/POTTERY
TOBACCO
GRAIN MILL
TRANSPORTATION
HEALTH CARE
TRUCKING AND STORAGE
HOTELS/MOTELS/CASINOS/
RESORTS
UPHOLSTERING
HOSPITALS/NURSING HOME
UTILITIES
IRON
WAREHOUSING
LUMBER
XII. As an arbitrator, please indicate your experience by SECTOR and check the appropriate box for the number of
cases for each sector identified.
SECTOR
1-4
5+
PUBLIC (NON-FEDERAL)
PUBLIC (FEDERAL)
PRIVATE
XIII. Registered with the Defense Finance and Accounting Service or Central Contractor Registration
XIV. LANGUAGE PROFICIENCY (Ability to conduct hearings):
Other (Specify):_________________
□ Spanish
□ French
□ Yes □ No
□ German
4
XV. I AM EXPERIENCED IN THE FOLLOWING TYPES OF ARBITRATION CASES AND AM WILLING TO
ACCEPT SUCH CASES:
EXPEDITED
□Yes □No
EMPLOYMENT
□ Yes
No
□
INTEREST
□ Yes □No
FACTFINDER
□Yes □No
XVI. I have FEDERAL SECTOR EXPERIENCE and can be considered for international arbitration assignments.
□ Yes
□ No
XVII. FEES CHARGED:
Per Diem:
$__________
Cancellation:
$__________
Docketing:
$ _________
Please explain your fee schedule in detail.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
XVIII. Award Citations:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
XIX. Publications:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
XX. DATE AVAILABLE FOR APPOINTMENT (MM/DD/YY)
_________/_________/_________
XXI. CERTIFICATION OF ADVOCACY
I hereby certify that, if admitted to the Federal Mediation and Conciliation Service (FMCS) Roster of Arbitrators, I will immediately
notify FMCS should I undertake any activities deemed to constitute "advocacy" under FMCS Regulations, 29 C.F.R. 1404.5(c), and
withdraw from the Roster.
Signature:
______________________________________________
Date: _______________________
I hereby affirm that the foregoing information is accurate, complete and true to the best of my knowledge. I understand that FMCS
has the right to verify any information contained herein. Any willful misrepresentation contained herein will constitute a basis for
rejection of this application by the FMCS Arbitrator Review Board. If approved by the Arbitrator Review Board, I affirm that I will
abide by FMCS Arbitration Policies and Procedures (29 C.F.R. 1404) and the Code of Professional Responsibility for Arbitrators of
Labor-Management Disputes. As a member of the FMCS Roster of Arbitrators, I affirm that any party that has selected me has the
right to verify any information listed on this application.
Signature:
_______________________________________________ Date: _______________________
5
FEDERAL MEDIATION AND CONCILIATION SERVICE
OFFICE OF ARBITRATION SERVICES
WASHINGTON, DC 20427
GEOGRAPHICAL LOCATIONS FOR ARBITRATORS
New York, NY
Long Island, NY
Albany, NY
Syracuse, NY
Buffalo, NY
Newark, NJ
Boston, MA
Worcester, MA
Hartford, CT
Providence, RI
Concord, NH
Portland, ME
Philadelphia, PA
Pittsburgh, PA
Erie, PA
Parkersburg, WV
Harrisburg, PA
Allentown, PA
Trenton, NJ
Baltimore, MD
Washington, DC
Richmond, VA
Atlanta, GA
Birmingham, AL
Mobile, AL
New Orleans, LA
Memphis, TN
Nashville, TN
Chattanooga, TN
Knoxville, TN
Charlotte, NC
Jacksonville, FL
Tampa, FL
Miami, FL
Cleveland, OH
Akron, OH
Toledo, OH
Columbus, OH
Dayton, OH
Cincinnati, OH
Louisville, KY
Detroit, MI
Saginaw, MI
1
101
102
103
104
105
106
107
108
109
110
111
112
213
214
215
216
217
219
220
221
222
223
326
327
328
329
330
331
332
333
334
335
336
337
441
442
443
444
445
446
447
448
449
Grand Rapids, MI
Kalamazoo, MI
Chicago, IL
Peoria, IL
Rockford, IL
South Bend, IN
Indianapolis, IN
Evansville, IN
Milwaukee, WI
Green Bay, WI
Minneapolis, MN
St. Louis, MO
Cedar Rapids, IA
Des Moines, IA
Omaha, NE
Kansas City, MO
Wichita, KS
Oklahoma City, OK
Springfield, MO
Little Rock, AR
Dallas, TX
Houston, TX
San Francisco, CA
Los Angeles, CA
San Diego, CA
Seattle, WA
Portland, OR
Spokane, WA
Great Falls, MT
Salt Lake City, UT
Denver, CO
Phoenix, AZ
Albuquerque, NM
Honolulu, HI
Sacramento, CA
Anchorage, AK
Cheyenne, WY
Lewiston, ID
Fargo, ND
Rapid City, SD
Las Vegas, NV
Jackson, MS
South Carolina
450
451
554
555
556
557
558
559
560
561
562
665
666
667
668
669
670
671
672
673
674
675
778
779
780
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
1
Virgin Islands
Toronto, Canada
Columbia, MO
Southern Illinois
Rochester, NY
Delaware
Vermont
Buffalo, NY
Kansas City, KS
Montreal, Canada
Reno, NV
Puerto Rico
801
813
815
816
817
819
821
806
822
823
824
835
Please circle only one city if you use one business address or two cities if you use two business addresses that is nearest the
address(es) you intend to establish your arbitration practice. For example, if your practice is located in The Woodlands, Texas,
you would circle Houston, TX only.
File Type | application/pdf |
File Title | FMCS Form R-22 |
Author | VTraynham |
File Modified | 2007-12-17 |
File Created | 2007-12-17 |