ࡱ> %` dbjbj"x"x C~@@{    ~~~aaa8btbDcc4ccceee8::::::$hed^~eeeee^  cc4shhhe Rc~c8he8hh* \"~rcc pB7aev6640lɻf>ɻlrr&ɻ~leeheeeee^^Xhjeeeeeeed$dZD$ZD       United Nations Dispute Tribunal Insert Applicants last namev.Secretary-General of the United NationsApplication Registry: To identify the Registry where your application should be filed, please refer to http://www.un.org/en/oaj/dispute/distribution.shtml UNDT case number: If unknown, leave blank. Date of application: Counsel for Applicant: If self-represented, please state so. Counsel for Respondent: If unknown, leave blank. Notice: This application should not exceed 10 pages (excluding supporting documents). I. Applicants general information Title (Mr., Mrs. or Ms.): Last name: First name: Middle name(s): If you are a former UN staff member, your separation date: If you are currently a UN staff member, your employment information: Type of appointment: Grade and step: Functional title: UN entity of employment/Department/Office/Section: Duty station: Notice: If you are filing your application through the eFiling portal (efilinginternaljustice.un.org), please proceed directly to section V on page 3. If you are unable to use the eFiling portal and are submitting your application by email, mail, or hand-delivery, please complete all sections below. UN Index number: Date of birth: Nationality: If submitting application on behalf of an incapacitated or deceased staff member: Last name of staff member: First name of staff member: Relationship to Applicant: II. Applicants employment information at the time of the contested decision Employment information at the time of the contested decision (if different from above): Type of appointment: Grade and step: Functional title: UN entity of employment/Department/Office/Section: Duty station: III. Applicants contact information Your contact information: Email address for correspondence: Optional email address: Cellular phone: Work phone: Home phone: Facsimile: Mailing address for service of documents: IV. Applicants representation If you nominate a legal representative, all case-related communications will be handled by the representative. Please attach your signed authorization for the legal representative. Are you assisted by a legal representative? Yes __ No __ If yes, identify whether you are represented by: __ OSLA; __ a volunteer (staff member or former staff member); or __ a private lawyer. Legal representatives contact information: Last name: First name: Place of work and functional title: Email address: Cellular phone: Work phone: Facsimile: Mailing address: If you are represented by a private lawyer, provide details of jurisdiction in which he or she is admitted to practice and date of admission to practice: V. Details of the contested decision Briefly describe what the decision was about: Name and title of official who made the decision: Name and title of author of the communication by which you were informed of the decision: Date on which the decision was made: Date on which the decision was notified to you or on which you first came to know about the decision: VI. Management evaluation Have you requested a management evaluation of the contested decision? Yes __ No __ If yes, when (date)? Have you received a response? Yes __ No __ If yes, date of the response and date on which you received it: VII. Summary of the facts of the case or facts relied upon Please state the facts in chronological order and as concisely as possible. Please number all paragraphs. VIII. Grounds for contesting the administrative decision Please state the arguments in support of your allegation that the contested decision was unlawful and/or improper, specifying any regulations, rules, or administrative issuances breached by this decision. Please number all paragraphs. IX. What remedies are you seeking? Please state the relief sought as concisely as possible. Please number all paragraphs. X. Supporting documents Please attach any material in support of your claim and number each attachment. Include your signed authorization for the legal representative, as well as copies of the contested decision, the request for management evaluation and the management evaluation, if any. If you include translations of any documents, please state so.Annex numberTitle (include nature of communication, author and addressee)Date (dd/mm/yyyy)1Authorization for the legal representative2Contested decision3Request for management evaluation4Management evaluation XI. Signature and certificationI hereby certify that to the best of my knowledge the information provided in this application form is true, accurate and complete and all copies submitted to the Dispute Tribunal are true copies of the original documents. 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