BEFORE THE
                              UNITED STATES DEPARTMENT OF LABOR
                             OFFICE OF ADMINISTRATIVE LAW JUDGES


Date:          _________________________
Case No(s).    _________________________


In the Matter(s) of:

________________________________________________
                         [Claimant or Complainant]     
     v.

________________________________________________
                         [Employer or Respondent]

     and

_________________________________________________
                         [Other interested party, if applicable]
     


                 REQUEST FOR APPOINTMENT OF SETTLEMENT JUDGE

     Pursuant to Rules of Practice and Procedure in Administrative Hearings Before the
Office of Administrative Law Judges, 29 C.F.R. § 18.9(e), the parties in the above
captioned matter jointly request the appointment of a settlement judge.


                          [Type name of parties or representatives]:

                          ________________________________________________________________
                          [ ] Pro Se  [ ] Counsel for Claimant or Complainant
                                             Telephone No. ___________________
                                             Fax No.       ___________________

                          ________________________________________________________________
                          [ ] Pro Se  [ ] Counsel for Employer or Respondent
                                             Telephone No. ___________________
                                             Fax No.       ___________________

                          ________________________________________________________________
                          [ ] Pro Se  [ ] Counsel for Other Interested Party
                                             Telephone No. ___________________
                                             Fax No.       ___________________