OAH 21B LOCAL AGENCY REQUEST TO SET (REV. 08/12) STATE OF CALIFORNIA OFFICE OF ADMINISTRATIVE HEARINGS TDD/TYY 800-735-2929 1515 CLAY STREET, SUITE 206 OAKLAND, CA 94612 Phone 510-622-2722 FAX 916-376-6323 1350 FRONT STREET, ROOM 3005 SAN DIEGO, CA 92101 Phone 619-525-4475 FAX 916-376-6325 2349 GATEWAY OAKS DR., SUITE 200 SACRAMENTO, CA 95833 Phone 916-263-0550 FAX 916-376-6349 320 WEST FOURTH STREET, ROOM 630 LOS ANGELES, CA 90013 Phone 213-576-7200 FAX 916-376-6324 LOCAL AGENCY REQUEST TO SET (Cal. Code Regs., tit. 1, § 1018) DATE: CASE TITLE NAME OF AGENCY AGENCY ATTORNEY/REPRESENTATIVE Name, Address, Telephone, E-mail & Fax Nos. RESPONDENT/APPELLANT/PETITIONER Name, Address, Telephone, E-mail & Fax Nos. FROM: OAH CASE NO. AGENCY CASE NO. RESPONDENT/ATTORNEY/REPRESENTATIVE Name, Address, Telephone, E-mail & Fax Nos. Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail EMPLOYEE DISCIPLINE STATUTORY TIME LIMIT YES NO PLEASE LIST EACH SEPARATELY ­ USE ADDITIONAL SHEETS IF NECESSARY DISABILITY RETIREMENT Preferred Method of Service: [ ]Email [ ]Fax [ ]U.S. Mail OTHER (List) IND DISABILITY RETIREMENT IF YES, PROVIDE LEGAL AUTHORITY (Code & Section No.) HEARING LOCATION IF YES, DATE BY WHICH CASE MUST BE HEARD (MONTH/DAY/YEAR) TIME ESTIMATE FOR HEARING HOURS DAYS DATES PREFERRED (ALL PARTIES) DATES AVAILABLE DATES UNAVAILABLE FOR AT LEAST 6 MONTHS (ALL PARTIES) DATES COORDINATED WITH ALL PARTIES? YES NO ADDITIONAL COMMENTS AND/OR INSTRUCTIONS WHICH WOULD AFFECT CALENDARING, REQUEST FOR ACCOMMODATION, SECURITY, ETC. ELECTRONIC RECORDING BY CONSENT (Gov. Code, § 11512, subd. (d)) (attach copy of written consent) OAH TO REQUEST COURT REPORTER AGENCY TO PROVIDE COURT REPORTER (If no selection is made a Court Reporter will be ordered and the agency will be charged.) NOTICE: This is not a reservation of dates. Completion of this form does not guarantee that you will receive the hearing dates requested. Dates are subject to availability at the time a Request to Set or other calendar request is processed by OAH. For more information visit www.dgs.ca.gov/OAH American LegalNet, Inc. www.FormsWorkFlow.com