STATE ARBITRATION BOARD

REQUEST FOR ARBITRATION OF A CLAIM

CONTRACT NO.: ______________

CLAIMANT'S NAME: ______________________________________________
MAILING ADDRESS: _____________________ _____________ ________ _________ 
                                             Street or P. O.Box                    City                       State             Zip

STATE JOB NO.: ______________________

JOB LOCATION: _______________________________________________________

The Claimant elects to:

_____ Submit only the written information attached to this request and, subject to agreement by  the Respondent party, waive an oral presentation to the Board.

OR

_____ Participate in a hearing before the Board to present testimony and exihibits.

The Claimant ( ___) will ( ___) will not have an attorney present at the hearing.

If a hearing is held, the Claimant will be represented by the following persons:

Name:                                             Title:
_______________________         ________________________
_______________________        ________________________
_______________________         ________________________
The Claimant requests that the Respondent have the following persons present at the hearing:
Name:                                            Title:

_______________________      _______________________

_______________________      _______________________

_______________________      _______________________

THE CLAIMANT ACKNOWLEDGES HAVING READ S 337.185, FLORIDA STATES AND THE OPERATING PROCEDURES OF THE STATE ARBITRATION BOARD.


_______ _______________________ ____________________________________
DATE             SIGNATURE                 TYPE OR PRINT NAME AND TITLE

MAIL THIS FORM AND ACCOMPANYING DOCUMENTS TO THE OFFICE OF THE STATE ARBITRATION BOARD
4/25/00