REQUEST FOR PANEL OF NEUTRAL INTEREST ARBITRATORS DO NOT WRITE IN THIS SPACE Requested by: Employee Organization Employer Joint Request EMPLOYE ORGANIZATION INFORMATION ____________________________________________________ Employe Organization ____________________________________________________ Contact Name ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone EMPLOYER INFORMATION ____________________________________________________ Public Employer ____________________________________________________ Contact Name ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone CASE NO. DATE FILED ____________________________________________________ Partial Arbitrator Name ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone ____________________________________________________ Partial Arbitrator Name ____________________________________________________ Address ____________________________________________________ City State Zip ____________________________________________________ Telephone Certification Case No.: Employer Budget Submission Date: PERA-R-______________________ Unit Type (check one): Court Related, Court Appointed Court Related, Non-Court Appointed Prison Guards Contract Expiration Date: Mediator: Unit Type (check one, or both if applicable): Professional Nonprofessional 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 PLRB-57 REV 2-10 American LegalNet, Inc. www.FormsWorkFlow.com