Appendix N EEO-MD-110

REQUEST FOR A HEARING FORM

EEOC Hearings Unit
____________________________ District/Field Office
__________________________________________________
__________________________________________________
__________________________________________________

Dear Sir/Madam:

I am requesting the appointment of an Equal Employment Opportunity
Commission Administrative Judge pursuant to 29 C.F.R. §
1614.108(g).  I hereby certify that either more than 180 days have
passed from the date I filed my complaint or I have received a
notice from the agency that I have thirty (30) days to elect a
hearing or a final agency decision.

     My name:  ________________________________________________
               ________________________________________________

     Agency    
     name &
     address   ________________________________________________
               ________________________________________________


     Agency No.:________________________________________________
                ________________________________________________


In accordance with section 1614.108(g), I have sent a copy of this
request for a hearing to the following person at the agency:

     Name:     ________________________________________________
               ________________________________________________



     Address   
     (if different
     from above)________________________________________________
                ________________________________________________

               

                                   Sincerely


                                   [Name of Appellant]

This page was last modified on November 8, 1999.

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