The U.S. Equal Employment Opportunity Commission

Appendix O EEO-MD-110

Notice of Appeal - Agency
to the Equal Employment Opportunity Commission
Office of Federal Operations
1. Ageny (please print or type):

2. Address:

3. Name of agency representative:

4. Telephone (including area code):                                                        E-mail address:

5. Name, address. telephone no. of complainant:

Complainant's Social Security No.:
6. If the complainant is represented, name, address, and telephone no. of representative:

7. Agency complaint number:

8. Name of Administrative Judge, District/Field Office location, and EEOC Hearings U nit No.:

9. Date of agency final action (include a copy):

10. T o your knowledge, does the complainant have any appeals pending at OFO? If so, please indicate the EEOC Appeal Nos.:

11. Signature of agency representative:                                                  Date:

NOTICE: Before mailing this appeal, please be sure to attach a copy of the final action and the Administrative Judge’s decision from which you are appealing. Please serve a copy of this appeal form on the complainant, with a copy of your final action. Any statement or brief in support of this appeal shall be submitted within twenty (20) days of the date this appeal is filed. Agencies must forward the complaint file to the EEOC within thirty (30) days of the submission of this appeal.
FOR EEOC USE ONLY:                                                                        OFO DOCKET NO.:

This page was last modified on July 18, 2005.

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