NEW YORK STATE PUBLIC EMPLOYMENT RELATIONS BOARD PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20 , ALBANY, NEW YORK 12220-0074 WWW.PERB.NY.GOV VOLUNTARY GRIEVANCE ARBITRATION RULES OF PROCEDURE DEMAND FOR ARBITRATION INSTRUCTIONS: Complete in full, retain one copy and distribute as follows: A) SERVE one copy upon respondent in the same manner as a summons or by registered or certified mail; return receipt requested; B) FILE an original and one (1) copy with the Director of Conciliation, NYS PER B, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, A LBANY, New York 122 20-0074, along with a $50 filing fee in the form of a check or money order made payable to the STATE OF NEW YORK. DATE: ____________________________ EMPLOYER Name of Employer . . . . . . . . . . Name, Title, Address, E-Mail, Telephone and Fax Number of the Representative to whom PERB should direct correspondence ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (E-mail) _______________________________________________________ (Telephone) ______________________ (Fax) _________________________ LABOR/EMPLOYEE ORGANIZATION Name of Organization . . . . . . . . Name, Title, Address, E-Mail, Telephone and Fax Number of the Representative to whom PERB should direct correspondence ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (E-mail) ________________________________________________________ (Telephone) ______________________ (Fax) __________________________ IDENTIFY PETITIONER (check one): EMPLOYER LABOR/EMPLOYEE ORGANIZATION IDENTIFY TYPE OF PANEL REQUESTED (check one): PUBLIC SECTOR VOLUNTARY GRIEVANCE ARBITRATION PANEL Available only to public sector employers and employee organizations. PRIVATE SECTOR REGULAR GRIEVANCE ARBITRATION PANEL Available only to private sector employers and labor organizations. PRIVATE SECTOR DIRECT APPOINTMENT PRO BONO PANEL Available only to private sector employers and labor organizations, whose collective bargaining agreement specifically provides for this service. American LegalNet, Inc. www.FormsWorkFlow.com PLEASE COMPLETE THE FOLLOWING, USING ADDITIONAL SHEETS IF NECESSARY: 1. Effective date and expiration date of the agreement: _____________________ to ______________________. (Mo./Day/Yr.) (Mo./Day/Yr.) 2. Identify the provision(s) in the agreement providing for arbitration and attach a copy thereof: 3. Identify the provision(s) in the agreement claimed to be violated and attach a copy thereof (use additional sheet(s) if necessary: 4. Write a clear and concise description of the nature of the dispute(s) to be arbitrated and the remedy(ies) sought (include the name(s) of the grievant(s)) (use additional sheet(s) if necessary): 5. Is proof of service of this Demand for Arbitration on the Respondent attached hereto? Yes No THE UNDERSIGNED, A P ARTY TO A WRITTEN AGREEMENT WHICH PROVIDES FOR ARBITRATION AS IDENTI FIED ABOVE, HEREBY DEMANDS ARBI TRATION. YOU ARE HEREBY NOTIFIED THA T COPIES OF THIS DEMAND F OR AR BITRATION ARE BEING F ILED WI TH THE D IRECTOR O F CONCILIATION, NEW Y ORK S TATE PUBLIC EMPLOY MENT RELATIONS BOARD, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, N EW YORK 1 2220-0074, W ITH TH E REQUEST THAT AN ARBITRATOR BE DESIGNATED IN ACCORDANCE WITH THE BOARD'S ESTABLISHED PROCEDURES AND POLICIES. IN ACCORDANCE WITH SECTION 7503(c) OF THE CIVIL PRACTICE LAW AND RULES (CPLR): "UNLESS THE PARTY SERVED APPLIES TO STAY THE ARBITRATION WITHIN TWENTY DAYS AFTER SUCH SERVICE HE SHALL THEREAFTER BE PRECLUDED FROM OBJECTING THAT A VALID AGREEMENT WAS NOT MADE OR HAS NOT BEEN COMPLIED WITH AND FROM ASSERTING IN COURT THE BAR OF A LIMITATION OF TIME." __________________________________ Signature _________________________ Title _______________ Date American LegalNet, Inc. www.FormsWorkFlow.com