Petition For Certification And Or Decertification

STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD PETITION FOR CERTIFICATION ANDIOR DECERTIFICATION INSTRUCTIONS: File an original and four (4) copies of this DO NOT WRITE I N THIS SPACE Petition with the Director of Public Employment Practices and Representation, New York State Public Employment Case No. CRelations Board, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NY 12220-0074. If more space is required Date Received: for any item, attach additional sheets, numbering item accordingly. The showing of interest and declaration of authenticity should not be affixed to the Petition. The Petitioner alleges that the following circumstances exist and requests that the New York State Public Employment Relations Board proceed under its proper authority. 1. Purpose of this petition. (Check only the lines which are appropriate.) A. ____ Certification of Negotiating Representative (Employee Organization) - A substantial number of employees wish to be represented for purposes of collective negotiations by petitioner and petitioner desires to be certified as representative of the employees for purposes of collective negotiations pursuant to Section 207 of the Act. B. ____ Representation (Employer) - One or more employee organizations have presented a claim to petitioner to be recognized as the negotiating representative of employees of Petitioner. C. ____ Decertification - Petitioner asserts that the currently recognized or certified negotiating representative should be deprived of representation status in whole or part. If Petitioner is an Employer, Petitioner asserts that the currently recognized or certified negotiating representative is defunct. 2. Name, address and telephone and fax numbers of Petitioner: Telephone Number: ___________________________ Fax Number: ________________________________ 3. Name, address and telephone and fax numbers of the representative, if any, to whom correspondence is to be directed: Telephone Number: ___________________________ Fax Number: ________________________________ 4. Name, address and telephone and fax numbers of Employer: Telephone Number: _________________________ Fax Number: ________________________________ 5. Description of negotiating unit claimed to be appropriate (Be complete and specific using job titles; attach a separate sheet if more space is needed): Included: Excluded: 6. a. Number of employees in unit: _____ b. Is this petition supported by a showing of interest, enclosed herewith, of 30% or more of the employees in the unit? ____ YES ____ NO c. Is the declaration of authenticity enclosed? ____ YES ____ NO American LegalNet, Inc. www.FormsWorkFlow.com 7. Request for recognition as negotiating representative was made: (Month, Day, Year) _____Has not replied (Explain on rider, if necessary) _____Declined recognition on ______________________(Month, Day, Year) 8. Recognized or certified negotiating agent (if there is none, so state): Name: Affiliation: Telephone Number: ________________ Fax Number: _____________________ Address: Date of recognition or certification: __________________________ (Month, Day, Year) 9. a. Employee organizations other than petitioner (and other than any named in Item 8 above) which claim to represent or are known to have an interest in representing any employees in the unit described in Item 5 above (if none, so state): Name/Address Affiliation b. Attach a separate sheet setting forth the name(s) and address(es) of the bargaining agent(s) for all other bargaining units of the employer. Include a brief description of each unit. 10. If the above-named employer is a party to a contract dealing with terms and conditions of employment for any of the titles listed in Item 5 above (if there is none, so state): (a) Name of the other party to the contract: ________________________________________________________ (b) Date of expiration of the contract: _______________________________(Month, Day, Year) (c) The negotiating unit specified in the contract: ___________________________________________________ (d) Is a copy of the contract attached? ____ YES ____ NO 11. The employer's fiscal year commenced on:_______________________ (Month, Day, Year) 12. Is this matter subject to Section 206.1 or 212 of the Act? ____ YES 13. If you have checked Box 1.A above: Do you affirm that you and the employee organization you represent or support do not assert the right to strike against any government, to assist or participate in any such strike, or to impose an obligation to conduct, assist, or participate in such a strike? ____ YES ____ NO 14. If you have checked Box 1.C above: (a) State the grounds upon which the certification should be revoked or the recognition annulled: ____ NO (b) Has the employee organization currently certified or recognized by the public employer engaged in a strike or caused, instigated, encouraged or condoned a strike against any government? ____ YES ____ NO 15. Include a clear and concise statement of any other relevant facts: I declare that I have read the above Petition and that the statements herein are true to the best of my knowledge and belief. ______________________________ (Signature of representative or person filing Petition) ______________________________ (Title, if any) Dated: ________________________________ PERB 519 (1/14) American LegalNet, Inc. www.FormsWorkFlow.com