BEFORE THE UNITED STATES DEPARTMENT OF LABOR OFFICE OF ADMINISTRATIVE LAW JUDGES Date: _________________________ Case No(s). _________________________ In the Matter(s) of: ________________________________________________ [Claimant or Complainant] v. ________________________________________________ [Employer or Respondent] and _________________________________________________ [Other interested party, if applicable] REQUEST FOR APPOINTMENT OF SETTLEMENT JUDGE Pursuant to Rules of Practice and Procedure in Administrative Hearings B efore the Office of Administrative Law Judges, 29 C.F.R. 18.9(e), the parties in t he above captioned matter jointly request the appointment of a settlement judge. [Type name of parties or representatives]: _____________________________________ Pro Se Counsel for Claimant or Complainant Telephone No. ___________________ Fax No. ___________________ _____________________________________ Pro Se Counsel for Employer or Respondent Telephone No. ___________________ Fax No. ___________________ _____________________________________ Pro Se Counsel for Other Interested Party Telephone No. ___________________ Fax No. ___________________ American LegalNet, Inc. www.USCourtForms.com