DILLS PETITION FOR CERTIFICATION DO NOT WRITE IN THIS SPACE: Case No.: Date Filed: INSTRUCTIONS: A Dills petition for certification must be filed with the PERB Sacramento regional office (address below), and must be accompanied by proof of support of at least 30 percent of the employees in the unit claimed to be appropriate. Proper filing includes concurrent service and proof of service of the petition as required by PERB Regulation 40170. Attach additional sheets if more space is required. 1. EMPLOYER State of California Department of Personnel Administration 1515 S Street, North Building, Suite 400 Sacramento, CA 95814-7243 (916) 324-0455 Employer's agent to be contacted: 2. DESCRIPTION OF PROPOSED UNIT Shall Include: (List each job classification, including the schematic code and class code) Title: Address and telephone, if different: Shall Exclude: ( ) Ext.________________ 3. APPROXIMATE NUMBER OF EMPLOYEES IN THE PROPOSED UNIT: 4. ORGANIZATION(S) KNOWN TO HAVE AN INTEREST IN REPRESENTING ANY OF THE EMPLOYEES COVERED BY THIS PETITION: Date of Recognition/ Name of Organization Address Certification (if any) 5. PETITIONER (Name, address and telephone number of employee organization) Petitioner's agent to be contacted: Title: Address and telephone, if different: _______________________________________________________ ( ) Ext. ______________ ( ) Ext. ______________ I declare that the statements herein are true to the best of my knowledge and belief, and that this petition is accompanied by proof of support of at least 30 percent of the employees in the proposed unit. PETITIONER'S AUTHORIZED REPRESENTATIVE: ________________________________________________________ (Signature) Date: ________________________________ Title: Sacramento Regional Office, 1031 18th Street, Suite 102, Sacramento, CA 95811-4124; (916) 322-3198 PERB-3005 (02/01) American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF DILLS PETITION FOR CERTIFICATION UNIT: _________________________ PERB CASE NUMBER: ______________________________ DATE NOTICE WAS POSTED: ____________________________ ON (DATE) , A PETITION FOR CERTIFICATION WAS FILED WITH THE PUBLIC EMPLOYMENT RELATIONS BOARD BY THE PETITIONER SHOWN ON THE DILLS PETITION FOR CERTIFICATION. THE PETITION IS BASED ON THE CLAIM THAT AT LEAST 30 PERCENT OF THE EMPLOYEES IN THE PROPOSED UNIT WISH TO BE REPRESENTED BY THE PETITIONING EMPLOYEE ORGANIZATION. SEE THE DILLS PETITION FOR CERTIFICATION FOR THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OF THE EMPLOYER AND THE PETITIONER. THIS NOTICE MUST REMAIN POSTED UNTIL:__________________________________ BY: ____________________________________________________________ (SIGNATURE OF EMPLOYER'S AUTHORIZED AGENT) PERB Regulation 40172 requires that this Notice be conspicuously posted on all employee bulletin boards in each facility of the employer in which members of the proposed unit are employed. The Notice should be posted as soon as possible but in no event later than 15 days following service of the petition on the employer. The Notice must remain posted for a minimum of 20 days. PERB-3005 (02/01) American LegalNet, Inc. www.FormsWorkFlow.com