FEDERAL MEDIATION AND CONCILIATION SERVICE

Form Approved

OMB No. 3076-0016 

Expires 11-30-2025 

FMCS Form R-43

Phone: (202) 606-5111 REQUEST FOR ARBITRATION PANEL 

2. UNION

1. EMPLOYER

4. Select the panel of arbitrators from below or see “Special Requirements” on page 2. See here for more information on Geographic Designations

Sub-Regional Metropolitan 125 mile radius from site of dispute. 60 mile radius from site of dispute.

6. Panel Size:

7. Type of Industry: Private Sector State or Local Government Federal Government

8. Payment: 

5. Type of Issue:

A panel of seven (7) names is usually provided. If this is a unilateral request, you must attach your relevant contract language 

which specifies a different number or “certify” on Page 2 that both parties have agreed to the number specified.

Privacy Act Statement. 29 U.S.C. § 172, et seq., authorize the FMCS to collect this information. The primary use of the information is to allow FMCS 

officials to maintain a roster of arbitrators. Additional disclosures of the information may be made: (1) to a Federal, State, or local law enforcement agency if 

FMCS becomes aware of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the 

Government is a party or in order to comply with a judge-issued subpoena; (3) to the National Archives and Records Administration or the General Services 

Administration in record management inspections; (4) to the Office of Management and Budget during legislative coordination on private relief legislation; (5) 

in a judicial or administrative proceeding if the information is relevant to the subject matter; (6) to provide arbitrator information to parties seeking arbitration 

services; and (7) information collected may be used by FMCS to provide information concerning FMCS trainings, events, presentations, conferences, and other 

educational opportunities and programs. This information is voluntary and will not be disclosed unless authorized by law. Failure to provide the requested 

information could result in not being included on FMCS's arbitration roster. 

9. On behalf of: Employer Union

Payment is made through Pay.gov. Contact payments@fmcs.gov for assistance if you are having difficulty with the Pay.gov 

payment process. 

Rev. September 2022

Requestor Name:

Company Name:

Representative Name: (Last) (First)

Street:

City: State Zip Code:

Phone:

E-mail:

Fax:

Union Name:

Representative Name: (Last) (First)

Street:

City: State Zip Code:

Phone: Fax:

E-mail:

3. Site of Dispute City: State Zip Code:

Regional

Please submit this form electronically at arbitration.fmcs.gov
REQUEST FOR ARBITRATION PANEL 

SPECIAL REQUIREMENTS 

Note: ALL requests on this page must be “CERTIFIED” as jointly agreed AND signed below. 

Requests on this page will NOT be honored without proper certification. 

□ Select panel from Nationwide

□ EXPEDITED ARBITRATION under FMCS Procedures

(See FMCS Arbitration Policies and Procedures, Subpart D, Section 1404.17 for specific requirements for Expedited

Arbitration.)

A panel will be sent based upon the request of a single party. If “Special Requirements” are listed or “Expedited 

Arbitration” is requested, you MUST certify that all parties jointly agree to these requests. This also applies to additional panel 

requests. If your contract contains these “Special Requirements,” including “Expedited Arbitration,” submit a copy of the 

relevant contract language only. A submission of a panel should not be construed as anything more than compliance with a 

request and does not reflect on the substance or arbitrability of the issue(s) in dispute. 

I certify that the above is jointly agreed. 

Name: Signature:

ADDITIONAL REQUIREMENTS: (For example, geographical restrictions, exclusions of arbitrators) 

_____________________________________________________________________________________ 

_____________________________________________________________________________________ 

SPECIALIZATIONS: 

Industry Specialization: _________________________________________________________ 

Issue Specialization: _________________________________________________________ 

ORGANIZATIONS or CERTIFICATIONS: 

□Attorney □AAA (American Arbitration Assoc.) □Industrial Engineer □NAA (National Academy of Arbitrators)