STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD APPLICATION FOR APPROVAL OF PROVISIONS AND PROCEDURES PURSUANT TO SECTION 212 OF THE CIVIL SERVICE LAW AND PERB RULE 203.1 INSTRUCTIONS: File the original and four DO NOT WRITE IN THIS SPACE copies of this application, together with two copies of the exhibits described below, with the Office of the Counsel, PO BOX 2074, ESP Case No. SAGENCY BLDG 2, FLS 18 & 20, ALBANY, NY 12220-0074. If you need more space for any item, attached additional sheets and Date Received: number the item the same as on this form. Application is hereby made to the Public Employment Relations Board for a determination that the local law, ordinance, resolution, or bylaw identified below is substantially equivalent to the provisions and procedures set forth in Article 14 of the Civil Service Law with respect to the State. 1. NAME OF LOCAL GOVERNMENT: ADDRESS: 2. (a) Official designation or number of local enactment submitted: (b) Date enacted: (c) Is this an amendment of a previous enactment? (d) If an amendment, has the Board found the previous enactment to be substantially equivalent to State Law and Rules? (e) If the answer to (d) is "Yes", has the Board determined that the continuing implementation of the previous enactment was substantially equivalent to State Law and Rules? Yes No Yes No Yes No American LegalNet, Inc. www.FormsWorkFlow.com 3. Names and addresses of any employee organizations that have been certified or recognized to represent any public employees of the applicant. (If none, state "None.") 4. Names and addresses of any other employee organizations that claim to represent any public employees of the applicant. (If none, state "None.") 5. Public notice of intention to file this application was posted at a conspicuous place at suitable offices of the applicant, on the following dates (not less than five working days): 6. The following designated exhibits are attached to and made part of this application: (a) Exhibit 1. A copy of the local law, ordinance, resolution, or bylaw adopted or amended by the legislative body of the applicant. (b) Exhibit 2. A copy of the public notice of intention to file this application, together with either an affidavit of publication in a newspaper of general circulation in the area of the applicant for at least one day, or a description of the manner and date of such publication. Dated: Name of person signing for local government Title Address Telephone No. PERB 25 (9/2008) American LegalNet, Inc. www.FormsWorkFlow.com