DILLS SEVERANCE PETITION DO NOT WRITE IN THIS SPACE: Case No.: Date Filed: INSTRUCTIONS: A Dills severance petition must be filed with the PERB Sacramento regional office (address below), and must be accompanied by proof of support of a majority 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 40200(c). 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: ( Title: Address and telephone, if different: ) Ext. _______________ 2. EXCLUSIVE REPRESENTATIVE OF ESTABLISHED UNIT (Name, address and telephone number) Agent to be contacted: Title: Address and telephone, if different: ( ) Ext. _______________ ( ) Ext. _______________ 3. DESCRIPTION OF PROPOSED UNIT Shall Include: (List each job classification, including the schematic code and class code) 4. TITLE AND NUMBER OF ESTABLISHED UNIT: 5. IF A CURRENT MEMORANDUM OF UNDERSTANDING EXISTS COVERING THE ESTABLISHED UNIT, INDICATE: MOU EFFECTIVE DATE: ___________________ MOU EXPIRATION DATE: ____________________ NO MOU IS IN EFFECT Shall Exclude: 6. APPROXIMATE NUMBER OF EMPLOYEES IN THE PROPOSED UNIT: 7. PETITIONER (Name, address and telephone number of employee organization) Petitioner's agent to be contacted: Title: Address and telephone, if different: __________________________________________________________ ( ) Ext. _______________ ( ) Ext. _______________ DECLARATION I declare that the statements herein are true to the best of my knowledge and belief, and that this severance petition is accompanied by proof of support of a majority of the employees in the proposed unit. PETITIONER'S AUTHORIZED REPRESENTATIVE: _______________________________________________________ (Signature) Title: Date: _____________________________ Sacramento Regional Office, 1031 18 Street, Suite 102, Sacramento, California 95811-4124 PERB-3105 (02/01) American LegalNet, Inc. www.FormsWorkFlow.com th NOTICE OF DILLS SEVERANCE PETITION UNIT: ____________________ PERB CASE NUMBER: _______________________ DATE NOTICE WAS POSTED: ____________________ ON (DATE) , A SEVERANCE PETITION WAS FILED WITH THE PUBLIC EMPLOYMENT RELATIONS BOARD BY THE PETITIONER SHOWN ON THE DILLS SEVERANCE PETITION. THE PETITION IS BASED ON THE CLAIM THAT A MAJORITY OF THE EMPLOYEES IN THE PROPOSED UNIT WISH TO BE REPRESENTED BY THE PETITIONING EMPLOYEE ORGANIZATION. SEE THE DILLS SEVERANCE PETITION FOR THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OF THE EMPLOYER, THE INCUMBENT REPRESENTATIVE, AND THE PETITIONER. THIS NOTICE MUST REMAIN POSTED UNTIL: _____________________ BY: ________________________________________________ (SIGNATURE OF EMPLOYER'S AUTHORIZED AGENT) PERB Regulation 40210 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-3105 (02/01) American LegalNet, Inc. www.FormsWorkFlow.com