REQUEST FOR APPOINTMENT OF FACT-FINDING PANEL DO NOT WRITE IN THIS SPACE Requested by: Employee Representative Employer Joint Request EMPLOYEE REPRESENTATIVE INFORMATION ____________________________________________________ Employee Organization ____________________________________________________ Chief Negotiator ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone CASE NO. DATE FILED ____________________________________________________ Additional Contact Name for Service List ____________________________________________________ Affiliation ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone EMPLOYER INFORMATION ____________________________________________________ Chief Negotiator ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone ____________________________________________________ Additional Contact Name for Service List ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone Contract Expiration Date: Mediator: SIGNATURE OF REQUESTING PARTY (IF JOINT REQUEST, BOTH PARTIES MUST SIGN FORM) Employee Representative's Signature: Employer's Signature: Date: Date: Department of Labor & Industry | Pennsylvania Labor Relations Board | 651 Boas Street, Room 418 | Harrisburg, PA 17121-0750 717.787.1091 | Fax 717.783.2974 | www.dli.state.pa.us Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com PLRB-25 5-09