Appendix M EEO-MD-110 REQUEST FOR A HEARING FORM
Management Directive 110
District/Field Office Name: | |
Address: | |
City, State, ZIP Code: | |
Fax number (if applicable): |
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.
Complainant's name (Last, First, M.I.: | |
Home/mailing address: | |
City, State, ZIP Code: | |
Daytime Telephone # (with area code): | |
Home or Mobile Phone # (with area code): | |
E-mail address (if any): | |
Agency Case Number: |
Attorney name: | |
Non-Attorney Representative name: | |
Address: | |
City, State, ZIP Code: | |
Telephone number (if applicable): | |
E-mail address (if any): | |
Fax Number (if any) |
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I will require the following reasonable accommodation(s) to participate in the hearing process:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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:
Agency EEO Office Representative name: | |
Address: | |
City, State, ZIP Code: | |
Fax number (if applicable): | |
E-mail address (if any): |
Signature of complainant or complainant's attorney: | |
Date: |
NOTE: Only Complainant or their attorney can sign the request for a hearing. Non-attorney representatives may not sign requests for a hearing. Hearing requests must be signed. Unsigned Hearing requests will not be assigned a hearing number or an Administrative Judge.
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