NATIONAL MEDIATION BOARD

APPLICATION FOR ADR SERVICES
Send to:
Chief of Staff/ADR Services
National Mediation Board
1301 K. Street, NW, Suite 250 East
Washington, DC 20572
Phone (202) 692-5030, Fax (202) 692-5084

PARTY OR PARTIES REQUESTING SERVICES
Name of Carrier:


 Name of Organization:
Carrier Official or Representative:


 Organization Official or Representative:
Address:


 Address:
City, State and Zip:


 City, State and Zip:
Telephone Number & Email Address:


 Telephone Number & Email Address:
Fax Number:


 Fax Number:
Signature of Carrier Official/ Representative & Date:


 Signature of Organization Official/ Representative & Date:

Craft or Class: ___________________________________________________

Type of Services Requested:
     
        IBB Training
        Grievance Mediation Training
        Other Training _________________________________________________
        Facilitation Services
        Grievance Mediation Services

Number of Participants (Training Only): ______

PLEASE COMPLETE APPLICATION IN FULL

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