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Appendix M EEO-MD-110 REQUEST FOR A HEARING FORM

Management Directive 110

To: The Commission Hearings Unit:

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 Information: (Please Print or Type)

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/Representative Information (if any):

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 Information:

Agency EEO Office Representative name:

Address:

City, State, ZIP Code:

Fax number (if applicable):

E-mail address (if any):
Complainant's Signature:

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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