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 MEDIATOR
The parties in the above captioned matter jointly request the appointment of a mediator for
☐ telephonic ☐ in-person mediation in ___________________________.
City, State
Name of the ALJ assigned (if that has occurred) to hear the case: ______________________
[Type name of parties or representatives]:
________________________________________________________________
[ ] Pro Se [ ] Counsel for Claimant or Complainant
Address ___________________
____________________
Telephone ___________________
Fax ___________________
Email ___________________
