Sacramento Regional Office 1031 18th Street, Suite 102 Sacramento, CA 95814 (916)322-3198San Francisco Regional Office 1330 Broadway, Suite 1532 Oakland, CA 94612-2514 (510)622-1016 PERB-6510 (/1) MMBA AGENCY SHOP RESCISSION PETITION DO NOT WRITE IN THIS SPACE: Case No.: Date Filed: REQUIREMENTS: 1.A petition for rescission of an existing agency shop agreement or provision may be filed with the appropriate PERB regional office(see PERB Regulation 32075), unless the employer has adopted local rules providing a procedure for rescission. The petition mustbe accompanied by proof of at least 30 percent support of the employees in the unit covered by the agency shop agreement orprovision. (Government Code section 3502.5(d) and PERB Regulations 61600 through 61630.)2.Each card or sheet of paper on which signatures of employees are obtained should state at the top that the undersigning employees are petitioning PERB to hold a secret ballot election to vote on rescission of the provision covering employees in the (title) unit.Proof of support shall conform to the requirements of PERB Regulation 61020(b), (c), (d)(3), (e), and (f). (Government Codesection 3502.5(d) and PERB Regulation 61600(c).)3.The petition, excluding the proof of at least 30 percent support, must be served on the employer and the exclusive representative. Proof of service, as defined in PERB Regulation 32140, shall be included with the petition. 1.EMPLOYER Name: Address: City, State Zip: Telephone: ()Ext. Employer222s agent to be contacted: Title: Address and telephone, if different: Address: City, State Zip: Telephone: ()Ext. E-Mail:2.EXCLUSIVE REPRESENTATIVE Name: Address: City, State Zip: Telephone: ()Ext. Agent to be contacted, if known: Title: Address and telephone, if different Address: City, State Zip: Telephone: ()Ext. E-Mail: 3.TITLE OF THE ESTABLISHED UNIT: 4.APPROXIMATE NUMBER OF EMPLOYEES IN THE ESTABLISHED UNIT: 5.INFORMATION REGARDING CURRENT WRITTEN AGREEMENT, IF ANY:EFFECTIVE DATE: EXPIRATION DATE: ARTICLE OR SECTION NUMBER, IF ANY, OF THE AGENCY SHOP PROVISION: 6.AUTHORIZED AGENT OF GROUP OF EMPLOYEES FILING RESCISSION PETITION: Name: Address: City:Zip:Telephone: ()Ext. E-Mail: I declare that the statements herein are true to the best of my knowledge and belief and that this agency shop rescission petition is accompanied by proof of at least 30 percent support of the employees in the established unit. PETITIONER222S AUTHORIZED AGENT: (Signature) Title (if any): Date: American LegalNet, Inc. www.FormsWorkFlow.com