Request for Grievance Arbitrator Panel

Please complete the form below. Note that fields marked with an asterisk (*) are required. Once the form has been submitted, you will receive an e-mail response with a copy of all data submitted. If you have any questions while completing the form, contact the Bureau at 651-649-5421.

Is the Employer a Private or Public organization?	*	Public Private

Name of EMPLOYER	*
EMPLOYER Address	*
City	*	St* Zip*
Name of CHIEF CONTACT	*
Check if the following information is the same as above:	*	Yes No
CHF CONTACT Address
City		St Zip
Daytime Phone	*	Ext.
Cell Phone
E-Mail Address	*
Check if the following information is the same as above:	*	Yes No
Name of LEGAL COUNSEL/CONSULTANT (if any)
COUNSEL/CONSULTANT Address
City		St Zip
Daytime Phone		Ext.
Cell Phone
E-Mail Address

Name of EXCLUSIVE REP	*
EXCLUSIVE REP Address	*
City	*	St* Zip*
Name of CHIEF CONTACT	*
Check if the following information is the same as above:	*	Yes No
CHF CONTACT Address
City		St Zip
Daytime Phone	*	Ext.
Cell Phone
E-Mail Address	*
Check if the following contact information is the same as above:	*	Yes No
Name of LEGAL COUNSEL/CONSULTANT (if any)
COUNSEL/CONSULTANT Address
City		St Zip
Daytime Phone		Ext.
Cell Phone
E-Mail Address

Type of Employer	*

Concise Statement of Nature of This Dispute and Unresolved Issues and Name of Grievant:	*

QUESTIONS: BUREAU AT 651-649-5421
NOTE: Once the Request has been submitted online, do NOT mail, fax or e-mail the original.

Date of Request:	*
Name of Person Filing this Request	*	Title
E-Mail Address of Person Filing this Request	*