NATIONAL RULES FOR THE RESOLUTION OF EMPLOYMENT DISPUTES Demand for Arbitration MEDIATION: If you would like the AAA to contact the other parties and attempt to arrange a mediation, please check this box. There is no additional administrative fee for this service. Name of Respondent Name of Representative (if known) Address: Name of Firm (if applicable) Representative’s Address City State City Fax No. Phone No. Zip Code Phone No. Email Address: State Zip Code Fax No. Email Address: The named claimant, a party to an arbitration agreement dated _________________________, which provides for arbitration under the National Rules for the Resolution of Employment Disputes of the American Arbitration Association, hereby demands arbitration. THE NATURE OF THE DISPUTE Dollar Amount of Claim $ Other Relief Sought: Attorneys Fees Interest Arbitration Costs Punitive/ Exemplary Other ____________ AMOUNT OF FILING FEE ENCLOSED WITH THIS DEMAND (please refer to the fee schedule in the rules for the appropriate fee) $ PLEASE DESCRIBE APPROPRIATE QUALIFICATIONS FOR ARBITRATOR(S) TO BE APPOINTED TO HEAR THIS DISPUTE: Hearing locale________________________ (check one) Requested by Claimant Locale provision included in the contract Estimated time needed for hearings overall: Claimant Employee Employer __________hours or ___________days Respondent Employee Employer Does this dispute arise out of an employment relationship? Yes No What was/is the employee’s annual wage range? Note: This question is required by California law. Less than $100,000 $100,000 - $250,000 Over $250,000 You are hereby notified that copies of our arbitration agreement and this demand are being filed with the American Arbitration Association’s Case Management Center, located in (check one) Atlanta, GA Dallas, TX East Providence, RI Fresno, CA International Centre, NY, with a request that it commence administration of the arbitration. Under the rules, you may file an answering statement within ten days after notice from the AAA. Signature (may be signed by a representative) Date: Name of Representative Name of Claimant Name of Firm (if applicable) Address (to be used in connection with this case) Representative’s Address City Zip Code City Fax No. Phone No. Phone No. Email Address: State State Zip Code Fax No. Email Address: To begin proceedings, please send two copies of this Demand and the Arbitration Agreement, along with the filing fee as provided for in the Rules, to the AAA. Send the original Demand to the Respondent. Please visit our website at www.adr.org if you would like to file this case online. AAA Customer Service can be reached at 800-778-7879 American LegalNet, Inc. www.FormsWorkflow.com