Official Legal Form
Request for Appointment of Mediator
Published by US Dept. of Labor — Forms. Mirrored here in its unmodified, original form for free public access.
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Administrative
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Jun 2026
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Jurisdiction: Intended for U.S. federal proceedings. Filing rules may vary by individual court.
Source: Published by US Dept. of Labor — Forms. View on official site →
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Form text
Extracted from the official PDF
U.S. Department of Labor Office of Administrative Law Judges
200 Constitution Ave., NW
Room S-4325
Washington, DC 20210
Mediation Program
Alison G. Smith, Mediator
smith.alison.g@dol.gov
BEFORE THE
UNITED STATES DEPARTMENT OF LABOR
OFFICE OF ADMINISTRATIVE LAW JUDGES
Date: _________________________
Case No(s). _________________________
In the Matter(s) of:
___________________________________
v.
___________________________________
and
___________________________________
REQUEST FOR APPOINTMENT OF MEDIATOR
The in the above captioned matter request the appointment of
a mediator for ☐ Microsoft Teams (Virtual).
Name of the assigned ALJ (if that has occurred): ______________________
Hearing Date (if scheduled): ______________________
________________________________________________________________
Address ___________________
___________________
Telephone ___________________
Fax ___________________
Email ___________________
________________________________________________________________
Address ___________________
___________________
Telephone ___________________
Fax ___________________
Email ___________________
Revised 8/26/2025
AGS 1 of 2
________________________________________________________________
Address ___________________
___________________
Telephone ___________________
Fax ___________________
Email ___________________
________________________________________________________________
Address ___________________
___________________
Telephone ___________________
Fax ___________________
Email ___________________
AGS 2 of 2
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