Form NMB 4 Personal Data Sheet09-30-2013

Form NMB-4 OMB No. 3140-0004 (Expiration Date 09/30/2013)

Arbitration Services – Personal Data Sheet

Date: ________________

I. Biographical

Name:	Mr.	Ms.	Last First Middle
Home Address:				City, State, Zip Code:
Home Telephone:				Home Fax:
Date of Birth:				Social Security #:
Name of Firm or Organization:				Title or Position:
Work Address:				City, State, Zip Code:
Work Telephone:				Work Fax:
Name of Firm or Organization:				Title or Position:
E-mail at Home:				E-mail at Work:

II. Education

Name of Institution & Complete Address:	Degree	Date	Major

III. Railroad and Airline Experience

Do you have previous Railroad or Airline Experience – exclusive of Arbitration? Yes  No 

If yes, complete the following information:

Name of Company/Organization & Complete Address:	Position	From	To

IV. Labor-Management Relations Experience (Include all experience unless disclosed in item III.)

Do you have previous Labor-Management Relations experience, - exclusive of Arbitration? Yes  No 

If yes, complete the following information:

Name of Company/Organization & Complete Address:	Position	From	To

Form Number Changed: This form was previously NMB - 8

Page 1 of 4 Instructions - Mail Pages 1 – 3 to:

Complete all pages: 1 through 3 Arbitration Services

See Privacy Act Notice on Page 4 National Mediation Board

Washington, DC 20572

Form NMB-4 OMB No. 3140-0004 (Expiration Date 08/31/2009)

Arbitration Services – Personal Data Sheet

V. Does your current employment or professional activity involve representation, advocacy, or participation in decision making for labor organizations or employers in any capacity?

Yes No  If yes, give a brief explanation:

VI. Present Federal, State, County of Local Government positions (include full-time, part-time, elected or appointed)

VII. Experience as an arbitrator - Estimated number (lifetime total) of Awards issued* by category:

Labor	Railroads	Airlines

*Five (5) awards must be submitted with your NMB Form 4.

VIII. Professional Rosters and memberships in Labor Relations Associations

(NAA, AAA, FMCS, etc.)

Form Number Changed: This form was previously NMB - 8

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Form NMB-4 OMB No. 3140-0004 (Expiration Date 08/31/2009)

IX Disclosures and Fee Arrangements:

Parties – Disclose any company or union which might question Check here if none  the advisability of your service as an arbitrator in a case.
List company or union here:
Other – Disclose any other limitation applicable to your service as an arbitrator. Check here if none 
Note other limitation here:
I will accept the Federal Government arbitrator rate when the Government is required to provide compensation.   Check here if you accept

10. Public Information:

Note: This form and information contained on this form, Arbitration Services – Personal Data Sheet – NMB-4, will not be disclosed to the public. If accepted to the roster, you will be required to submit a resume which will be provided to the parties to assist them in selecting the arbitrator best qualified to hear their disputes.

10. References:

Name	Title/Position	Organization	Telephone

XII. Certification: To the best of my knowledge, I certify that the information I have provided on Form NMB-4 is correct.

___________________________________________ _______________

Signature Date

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Form Number Changed: This form was previously NMB - 8

Form NMB-4 OMB No. 3140-0004 (Expiration Date 08/31/2009)

PRIVACY ACT NOTICE

Pursuant to Section 3 (e)(3) of the Privacy Act of 1974 (Public Law 93-579), the individual furnishing information on the Form NMB-4, Arbitration Services Personal Data Sheet, is hereby advised as follows:

Authority – Section 201.(b) of the Labor Management Relations Act of 1974 and 29 CFR 1404 constitute the authority for soliciting this information.

Purpose and Use – The information provided on this form will be used by the NMB Office of Arbitration Services to evaluate applicants for possible inclusion on the NMB roster of arbitrators and to update the information relative to current roster members. If accepted to the roster, pertinent information will be provided to the parties requesting arbitrators to assist the parties in selecting the arbitrator best qualified to hear their dispute.

Effects on Non-disclosure – While completion of this form is voluntary, no individual will be admitted to the NMB Roster of Arbitrators unless pages 1 –3 of NMB-4 are completed and submitted to the agency.

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