STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD EMPLOYER APPLICATION FOR DESIGNATION OF PERSONS AS MANAGERIAL OR CONFIDENTIAL INSTRUCTIONS: File an original and four (4) copies of this Application with the Director of Public Employment Practices and Representation, New York State Public Employment Relations Board, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NY 12220-0074 and simultaneously mail notice of the filing of the Application (a) to titles alleged to be managerial or confidential, and (b) to any employee organization which has been recognized or certified to represent any such persons. If more space is required for any item, attach additional sheets, numbering item accordingly. Copies of all relevant job descriptions must be attached. DO NOT WRITE IN THIS SPACE Case No. EDate Received: The Employer alleges that the following circumstances exist and requests that the New York State Public Employment Relations Board proceed under its proper authority. 1. Name of Employer: Address of Employer (No. & Street, City & Zip Code, County): Telephone Number: 2. Name of representative, if any, to whom correspondence is to be directed: Address of representative (No. & street, City & Zip Code, County): Telephone Number: 3. The Employer requests that the following job titles be designated as MANAGERIAL Job Title and Name of Individual 1. ____________________________ 2. ____________________________ 3. ____________________________ 4. ____________________________ 5. ____________________________ 6. ____________________________ 7. ____________________________ 8. ____________________________ CONFIDENTIAL Job Title and Name of Individual 1. ___________________________ 2. ___________________________ 3. ___________________________ 4. ___________________________ 5. ___________________________ 6. ___________________________ 7. ___________________________ 8. ___________________________ (Use additional sheet(s), if necessary.) American LegalNet, Inc. www.FormsWorkFlow.com 4. (a) If any of the job titles listed in paragraph 3 are within a unit presently represented by a recognized or certified employee organization, set forth the name, address and telephone number of the employee organization(s), and identify which title(s) it represents. (b) If any of the job titles listed in paragraph 3 are not within a unit, set forth the name, address and title of the person in each such title. (c) If any employee organization is presently seeking to represent any of the job titles which are listed in paragraph 3, set forth the name, address and telephone number of the employee organization(s) and identify which titles it is seeking to represent. 5. Has the Employer ever filed an Application seeking the designation of any of these job titles as managerial or confidential? ____ YES ____ NO If Yes, set forth the Case Number(s): _______________ 6. Has the Employer served notice of the filing of this Application on (a) each of the persons who are within any of the job titles alleged to be managerial or confidential, and (b) on any employee organization which has been recognized or certified to represent any such person? ____ YES ____ NO 7. Set forth a clear and concise factual statement in support of this Application. I declare that I have read the above Application and that the statements herein are true to the best of my knowledge and belief. ____________________________________ Employer By _____________________________ (Signature of attorney or representative filling the Application) _______________________ (Title) Date: ___________________________ PERB 575 (1/14) American LegalNet, Inc. www.FormsWorkFlow.com