NEW YORK STATE PUBLIC EMPLOYMENT RELATIONS BOARD 80 WOLF ROAD, ALBANY, NEW YORK 12205 VOLUNTARY GRIEVANCE ARBITRATION RULES OF PROCEDURE SUBMISSION TO ARBITRATE INSTRUCTIONS: Complete in full, retain one copy each and forward an original and one (1) copy to the Director of Conciliation, NYS PERB, 80 Wolf Road, Albany, New York 12205, along with the $50.00 per party filing fee in the form of a check or money order made payable to the State of New York. DATE: ______________________ 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 the provision(s) in the agreement claimed to be violated and attach a copy thereof: 2. 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)): ________________________________ THE PARTIES NAMED HEREIN, HEREBY JOINTLY REQUEST BINDING ARBITRATION OF THE DISPUTE DESCRIBED HEREIN UNDER THE VOLUNTARY ARBITRATION RULES OF PROCEDURE OF THE NEW YORK STATE PUBLIC EMPLOYMENT RELATIONS BOARD. ___________________________________________ Signature of Public Employer Representative __________________ Title ___________ Date __________________________________________ Signature of Employee Organization Representative __________________ Title ___________ Date American LegalNet, Inc. www.USCourtForms.com