Form #A-21

__________________________________________________________________________________________________________
Board or State Association

__________________________________________________________________________________________________________
Address

City

State

Zip

Action of the Appeal Hearing Tribunal

(Arbitration Request)
The decision of the Grievance Committee (or Hearing Panel) to dismiss the arbitration request in the matter of:
___________________________________________________ vs. __________________________________________________
Complainant

Respondent

dated ______________________, was appealed by ______________________ and was considered on ________________________

Date

Appellant

Date

by the Appeal Tribunal of the Board of Directors of ______________________.

Board/Association

The Appeal Tribunals decision in the above-referenced case is to:

pDeny the appeal and uphold the Grievance Committees (Hearing Panels) decision.
pGrant the appeal and overturn the Grievance Committees (Hearing Panels) decision. This matter is hereby referred to a hearing
before the Professional Standards Committee. You will be notified in the near future concerning a hearing date.

The decision above was rendered by an Appeal Tribunal of the Board of Directors of the ______________________ comprised
Board/Association
of the following members whose signatures are affixed below.
The appeal was considered and decision deemed final on ___________________.
Date

________________________________________, Chairperson

____________________________________________, Member

_______________________________________________________________
Signature

_______________________________________________________________
Signature

Type/Print Name

________________________________________, Member
Type/Print Name

Type/Print Name

__________________________________________, Member
Type/Print Name

_______________________________________________________________
Signature

_______________________________________________________________
Signature

________________________________________, Member
Type/Print Name

_______________________________________________________________
Signature

(Adopted 11/01)
237

Code of Ethics and Arbitration Manual