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 MEDIATION
(Pursuant to § 111.11 of WEPA or §§ 111.70(4)(c)1, or (4)(cg)3, or (4)(cm)3 of MERA or § 111.87 of SELRA)
	
INITIATING PARTY OR PARTIES:	THE FILING FEE FOR MEDIATION 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.	
	Labor Organization		
	Employer		
	Joint		

All Information is Required
	
Name of 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	
				
Describe the Collective Bargaining Unit Involved with Inclusions and Exclusions	

	
Select One:	

  Contract Negotiation Dispute	

  Grievance Dispute	

  Other Labor Dispute	

List and Describe the Issue(s) in Dispute	

 The initiating party requests that the Commission assigns a Commissioner or WERC Staff Member as Mediator.	

 The parties jointly request the following Commissioner or WERC Staff Member as Mediator (if available)	

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

I declare that 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