EERA REPRESENTATION PETITION DO NOT WRITE IN THIS SPACE: Case No.:Date Filed: INSTRUCTIONS: A request for recognition, severance request or intervention is to be filed with the employer. Proper filing includes concurrent service and proof of service of the request/severance/intervention as required by PERB Regulations 33050 and 33070. Attach additional sheets if more space is required. 1.EMPLOYER (Name, address and telephone number)() Ext. Employer's agent to be contacted: Title: Address and telephone, if different: () Ext. 2.TYPE OF PETITION (Check one) REQUEST FOR RECOGNITION SEVERANCE REQUEST INTERVENTION3.PROOF OF SUPPORT (Check one) Majority support filed with PERB At least 30 percent support filed with PERB 4.DESCRIPTION OF PROPOSED UNITShall Include:5.IF A CURRENT WRITTEN AGREEMENT EXISTS COVERINGEMPLOYEES IN THE PROPOSED UNIT, INDICATE :AGREEMENT EFFECTIVE DATE:AGREEMENT EXPIRATION DATE: NO AGREEMENT IS IN EFFECT. Shall Exclude: 6.NUMBER OF EMPLOYEES IN PROPOSED UNIT: . 7.ORGANIZATION(S) RECOGNIZED OR CERTIFIED AS THE EXCLUSIVE REPRESENTATIVE OF OR KNOWN TO HAVE ANINTEREST IN REPRESENTING ANY OF THE EMPLOYEES COVERED BY THIS PETITION:Date of Recognition Name of Organization Address Certification (if any) 8.PETITIONER (Name, address and telephone number)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. PETITIONER'S AUTHORIZED REPRESENTATIVE: (Signature) Title: Date: Sacramento Regional Office 1031 18th Street, Room 102 Sacramento, CA (916)322-3198San Francisco Regional Office 1330 Broadway, Ste 1532Oakland, CA 94612-2514 (510)622-1016 PERB-2110 (0/) American LegalNet, Inc. www.FormsWorkFlow.com NOTICEOFEERAREPRESENTATIONPETITION PERB CASE NUMBER: DATE NOTICE WAS POSTED: ON , THE PETITION INDICATED BELOW WAS FILED WITH THE (Date) EMPLOYER BY THE PETITIONER SHOWN ON THE . REQUEST FOR RECOGNITION SEVERANCE REQUEST INTERVENTION THE PETITION IS BASED ON THE CLAIM THAT (CHECK ONE) A MAJORITY AT LEAST 30% OF THE PROPOSED UNIT WISH TO BE REPRESENTED BY THE PETITIONER. NOTICE - REQUEST FOR RECOGNITION/SEVERANCE ONLY: EXCEPT AS PROVIDED BY PERB REGULATION 33700(C), ANY OTHER EMPLOYEE ORGANIZATION DESIRING TO REPRESENT ANY OF THE EMPLOYEES IN THE UNIT DESCRIBED IN THIS REQUEST FOR RECOGNITION/ SEVERANCE REQUEST HAS THE RIGHT, WITHIN 15 WORKDAYS FOLLOWING THE DATE OF THIS NOTICE, TO FILE WITH THE EMPLOYER AN INTERVENTION SUPPORTED BY AT LEAST 30% OF THE EMPLOYEES IN A UNIT CLAIMED TO BE APPROPRIATE. THE LAST DATE FOR FILING AN INTERVENTION IS: . SEE THE FOR THE NAMES, ADDRESSES AND TELEPHONE NUMBERS OFTHE EMPLOYER, THE INCUMBENT EXCLUSIVE REPRESENTATIVE (IF ANY), AND THE PETITIONER. THIS NOTICE MUST REMAIN POSTED UNTIL: BY: (SIGNATURE OF EMPLOYER'S AUTHORIZED AGENT) PERB Regulations 33060 and 33080 require 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 10 days following receipt of the petition. The Notice must remain posted for at least 15 workdays. PERB-2110 (0/) American LegalNet, Inc. www.FormsWorkFlow.com