NEW YORK STATE PUBLIC EMPLOYMENT RELATIONS BOARD PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NEW YORK 12220-0074 J O I N T R E Q U E S T F O R S T A F F G R I E V A N C E M E D/ A R B FOR OFFICE USE ONLY INSTRUCTIONS: Complete in full, retain one copy each and forward the original and one (1) copy to the Director of Conciliation, NYS PERB, Case No. __________ Date of Filing: PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NY 12220-0074. To be processed, the Accepted:__________________ __________________ __________________ _________________ _ joint request must be accompanied by a check Declined: fifty dollars from each party in the amount of ($50.00), made out to "STATE OF NEW YORK". DATE: Date of A/D: _________ Assigned: PUBLIC EMPLOYER Name of Public Employer . . Name, title, address and telephone number of the representative to whom PERB should direct correspondence. EMPLOYEE ORGANIZATION Name of Employee Organization . Name, title, address and telephone number of the representative to whom PERB should direct correspondence. (ATTACH ADDITIONAL SHEETS WHERE NECESSARY) 1. IDENTIFY DATES ON WHICH BOTH PARTIES ARE AVAILABLE FOR MED/ARB SESSIONS: 2. IDENTIFY THE PROVISION(S) IN THE AGREEMENT CLAIMED TO BE VIOLATED AND ATTACH A COPY THEREOF: FORM CONTINUED ON REVERSE SIDE American LegalNet, Inc. www.FormsWorkFlow.com 3. WRITE A CLEAR AND CONSISE DESCRIPTION OF THE ISSUE(S) IN DISPUTE AND THE REMEDY(IES) SOUGHT (INCLUDE THE NAME(S) OF THE GRIEVANT(S)]: THE PARTIES NAMED HEREIN, HEREBY JOINTLY REQUEST STAFF MED/ARB TO PROVIDE A FINAL AND BINDING RESOLUTION OF THE DISPUTE DESCRIBED HEREIN. THE PARTIES AGREE THAT THEY HAVE RECEIVED AND READ A COPY OF PERB'S "PRELIMINARY GUIDELINES REGARDING STAFF GRIEVANCE MED/ARB PILOT PROJECT", AND UNDERSTAND THAT THIS MATTER WILL BE CONDUCTED PURSUANT TO THE CONDITIONS AND PROCEDURES SET FORTH IN THOSE GUIDELINES. THE PARTIES FURTHER STIPULATE AND AGREE THAT: (a) (b) (c) (d) The person assigned by PERB will serve as both mediator and, if necessary, arbitrator of the issue(s) in dispute. The med-arbitrator will be a full-time member of PERB's professional staff. The issue(s) in dispute is arbitrable under the terms of the parties' collective agreement. Should this matter proceed to arbitration, the award issued by the PERB medarbitrator is final and binding and may not be appealed to PERB or any of its officers, employees, or members. Judicial review of any award issued by the PERB med-arbitrator may be sought only under CPLR Article 75. (e) Signature of Public Employer Representative Title Date Signature of Employee Organization Representative Title Date American LegalNet, Inc. www.FormsWorkFlow.com