Request For Conciliation

SD EForm - 1653 V1 SD SOUTH DAKOTA DEPARTMENTREGULATION DEPARTMENT OF LABOR AND OF LABOR DIVISION OF LABOR AND MANAGEMENT DIVISION OF LABOR AND MANAGEMENT , Petitioner, vs. , Respondent. HF No. REQUEST FOR CONCILIATION 1. Employee or Employee Organization: Name of contact person: Address: Telephone: Employer Name of contact person: Address: Telephone: Date written statement of Impasse delivered: Contracts Issued: Yes No 2. 3. 4. 5. 6. Place where meeting can be held: Brief statement of nature of impasse: _______________________________ Signature of Person or Organization requesting Conciliation DOL-LM 8/02 1 American LegalNet, Inc. www.FormsWorkFlow.com