Arbitration Information Form

Arbitrator Information Form

	Biographical Information:

	Name:
	Prefix:		First Name:		Middle Initial/Name:		Last Name:		Suffix:


	Primary Business Address:
	Position Title:
	Organization:
	Address 1:
	Address 2:
	City:
	State:		Zip Code:
	Country:
	Phone:
	Fax:
	Email:


	Secondary Business Address:
	Position Title:
	Organization:
	Address 1:
	Address 2:
	City:
	State:		Zip Code:
	Country:
	Phone:
	Fax:
	Email:


	Home Address:
	Address:
	City:
	State:		Zip Code:
	Country:
	Phone:
	Fax:


	Birth Info:
	Date of Birth:	Month:	Day:	Year(4 digits):


	Place of Birth:	City:	State:	Country:

	Occupation: (check all that apply)
		Arbitrator	Mediator
		Fact-Finder	Administrator
		Professor/Educator	Attorney
		Other:

	Hearing Record Practice: (check all that apply)
		Court Reporter
		Tape Recorder
		Personal Notes
		Other:

	Cancellation / Per Diem Information:

	Cancellation fee charged:			Yes No
	Cancellation fee amount:


	Circumstances under which cancellation fee is charged:


	Per Diem Rate:
	Per Diem Information:

	Education:
		Degree	Major	School	Year

	Certifications:
		State	Year	Certification

	Employment History:(List most recent position first)
		Employer	Position Held	From Year	To Year

	Labor Relations Activities:(List labor activities not detailed elsewhere in this form)
		List of labor relations activites.

	Membership Information:

	National Academy of Arbitrators:
		NAA member:	Yes	No


	Labor Arbitrator Panel Memberships:
		American Arbitrator Association (AAA) member:		Yes
		Federal Mediation and Conciliation Service (FMCS) member:		Yes


	National, State, and Permanent Panels:


	Professional Memberships:(ex. IRRA, SPIDR,ABA, etc.)
		List of Professional Memberships:

	Awards and Honors:(List name of award/honor, presenting organization, date)

	Publications: (Do not include published arbitration awards.)
		Title:	Journal/Publisher:	Volume:	Issue:	Date:

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