State of Wisconsin
Employment Relations Commission
2418 Crossroads Drive, Suite 1000, Madison, WI  53718-7896
Phone:  608-243-2424    Fax:  608-243-2433
Email:  werc@werc.state.wi.us	

REQUEST TO INITIATE GRIEVANCE ARBITRATION
(Pursuant to § 111.10 of WEPA or §§ 111.70(4)(c) or (4)(cg) of MERA or § 111.86 of SELRA)
	
REQUESTING PARTY OR PARTIES:	THE FILING FEE FOR GRIEVANCE ARBITRATION IS $800 SPLIT EQUALLY BETWEEN BOTH PARTIES.  PROCESSING BEGINS WHEN A REQUEST AND $400 IS RECEIVED, AT WHICH TIME THE OTHER PARTY IS BILLED BY THE COMMISSION FOR THE REMAINING $400.	
	Employee or Labor Organization		
	Employer		
	Joint		

All Information is Required
	
Name of Employee or Labor Organization	Name of Employer	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
Name of Representative	Name of Representative	
		
Street Address, City, State, Zip Code (if different)	Street Address, City, State, Zip Code (if different)	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
Name of Representative 2	Name of Representative 2	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
Briefly describe the nature of the grievance (example:  J. Smith Discharge) and attach a copy of the grievance, the employer’s response thereto, and the entire collective bargaining agreement involved.	

	
The initiating party(ies) may request the appointment or submission of one of the following to issue a final and binding arbitration award. Select Applicable Statement:	

  A WERC commissioner or staff member to serve as sole arbitrator or as arbitration board chair.	
The parties jointly request (if available)	

  A panel of WERC commissioners/staff members	
Number of names requested	

  A panel of ad hoc arbitrators
(No Filing Fee or Collective Bargaining Agreement Required)	
Number of names requested	

	
Date Form Was Sent to the Commission and, Unless the Request is Joint, to the Other Party		

Arbitration awards issued by employees of the Wisconsin Employment Relations Commission are public records and are published on the Commission’s website. Copies of any arbitration awards received from Non-WERC ad hoc arbitrators are considered public records but not published on WERC’s website. 
	
I declare I have read the contents of this request and that the statements are true and correct to the best of my knowledge.	
Name		Title		
Signature		Date		
Name		Title		
Signature		Date