STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD WWW.PERB.NY.GOV File an original and three (3) copies of this charge with the Director of Employment Practices and Representation, Public Employment Relations Board, PO BOX 2074, ESP AGENCY BLD 2, FL18-20, ALBANY, NY 12220-0074. If more space is required for any item, attach additional sheets, numbering each item accordingly. DO NOT WRITE IN THIS SPACE Case No.: Date Received: 1.Name of employer Telephone 2. Address of employer (including Zip Code) 3. Address at which alleged unfair labor practices occurred 4. General nature of business 5. Approximate total number of employees 6. Number of employees involved in alleged unfair labor practices 7. Nature of work done by employees involved CHARGE 8.Pursuant to Section 706 of the New York State Employment Relations Act, the undersigned hereby charges that the above-namedemployer has engaged in and is engaging in unfair labor practices within the meaning of Section 704 of said Act, in that ( Specify theparticular alleged violation, with a brief statement of the facts supporting the charge, use additional sheet(s) if necessary. You must alsoidentify the subsections of Sections 704 of the Act which are alleged to have been violated and include all the facts required by Section252of the Private Sector Rules of Procedure available at our website.) 9.Approximate percentage and volume of sales to, and purchases from, points outside New York State.10.Any other facts concerning interstate commerce.11.Whether NLRB has accepted or declined jurisdiction over the employer.Form continues on following page. Reset Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com SS.: Name of person or labor organization making the charge (If made by a labor organization, give the name and official position of the person acting for the organization.) 205 205205205205205205205205205205205205205205205205205205. 205205205205205 205205205205205205205205205205205205205205205205205205205. 205205205205205 205205205205205205205205205205205205205205205205205205205205205205205205205205 (Signature) (Signature) Sworn to before me Address 205205205205205205205205205205205205205205205205205205. (Include Zip Code) this day of 20 Telephone No 205205205205205205205205205205205205205205205205205205 205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205205. ULPC (5-17) STATE OF NEW YORK CITY OF COUNTY OF 205205205205205205205205205205205205205205205205 . being duly sworn, deposes and says that he/she has read the foregoing charge and knows the contents thereof: that the same is true to his/her own knowledge, except as to the matters therein stated to be alleged on information and belief, and as to those matters he/she believes to be true. Fax No: 205 205205205205205205.205205205205205205205. Email: 205 205205205205205205205205205205205205205.. Reset Form Reset Form Reset Form American LegalNet, Inc. www.FormsWorkFlow.com