AC Petition {NLRB-502 (AC)}

FORM NLRB-502 (AC) (2-18)UNITED STATES OF AMERICA NATIONAL LABOR RELATIONS BOARD AC PETITION Case No. Date Filed INSTRUCTIONS: Unless e-Filed using the Agency's website, , submit an original of this Petition to an NLRB Office in the Region in which the employer concerned is located. 1. PURPOSE OF THIS PETITION: AC-AMENDMENT OF CERTIFICATION - Petitioner seeks amendment of previous NLRB certification. The Petitioner alleges that the following circumstances exist and requests that the National Labor Relations Board proceed under its proper authority pursuant to Section 9 of the National Labor Relations Act. 2a. Name of Employer 2b. Address(es) of Establishment(s) involved (Street and number, city, state, ZIP code) 3a. Employer Representative - Name and Title 3b. Address (If same as 2b - state same) 3c. Tel. No. 3d. Cell No. 3e. Fax No. 3f. E-Mail Address 4a. Type of Establishment (Factory, mine, wholesaler, etc.) 4b. Principal product or service 5a. Description of Unit Involved Included: Excluded: 5b. City and State where unit is located: 6. Unit previously certified in Case: 7. Description of the desired amendment: 8. Reasons for desired amendment: 9a. Name of Recognized or Certified Bargaining Agent 9b. Address 9c. Tel. No. 9d. Cell No. 9e. Fax No. 9f. E-Mail Address 9g. Affiliation 10a. Date of Recognition or Certification 10b. Expiration Date of Current or Most Recent Contract, if any (Month, Day, Year) 11. Organizations or individuals other than Petitioner and those named in item 9, who claim to represent any employees affected by the proposed clarifications. (If none, so state) 11a. Name and affiliation, if any 11b. Address 11c. Tel. No. 11d. Cell No. 11e. Fax No. 11f. E-Mail Address 11g. Description of contract covering those employees 12. Full Name of Petitioner (including local name and number if applicable) 12a. Address (Street and number, city, state, ZIP code) 12b. Full name of national or international labor organization of which Petitioner is an affiliate or constituent (if none, so state) 12c. Tel. No. 12d. Cell No. 12e. Fax No. 12f. E-Mail Address 13. Representative of the Petitioner who will accept service of all papers for purposes of the representation proceeding. 13a. Name and Title 13b. Address (Street and number, city, state, ZIP code) 13c. Tel. No. 13d. Cell No. 13e. Fax No. 13f. E-Mail Address I declare that I have read the above petition and that the statements are true to the best of my knowledge and belief. Name (Print) Signature Title Date FiledWILLFUL FALSE STATEMENTS ON THIS PETITION CAN BE PUNISHED BY FINE AND IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001) PRIVACY ACT STATEMENT Solicitation of the information on this form is authorized by the National Labor Relations Act (NLRA), 29 U.S.C. 247240151 et seq. The principal use of the information is to assist the National Labor Relations Board (NLRB) in processing representation and related proceedings or litigation. The routine uses for the information are fully set forth in the Federal Register, 71 Fed. Reg. 74942-43 (Dec. 13, 2006). The NLRB will further explain these uses upon request. Disclosure of this information to the NLRB is voluntary; however, failure to supply the information may cause the NLRB to decline to invoke its processes. DO NOT WRITE IN THIS SPACE American LegalNet, Inc. www.FormsWorkFlow.com