STATE OF NEW YORK PUBLIC EMPLOYMENT RELATIONS BOARD PETITION FOR UNIT CLARIFICATION AND/OR UNIT PLACEMENT INSTRUCTIONS: File an original and four (4) copies of this Petition with the Director of Public Employment Practices and Representation, N.Y.S. Public Employment Relations Board, PO BOX 2074, ESP AGENCY BLDG 2, FLS 18 & 20, ALBANY, NY 12220-0074. If more space is required for any item, attach additional sheets, numbering according to the petition item. DO NOT WRITE IN THIS SPACE Case No. CPDate Received: The Petitioner alleges that the following circumstances exist and requests that the New York State Public Employment Relations Board proceed under its proper authority. 1. Purpose of this petition. (Check the appropriate line.) A. ____ B. ____ Unit Clarification ­ a position is encompassed within the scope of an existing unit. Unit Placement ­ a position should be placed into an existing unit pursuant to the criteria set forth in Section 207 of the Act. 2. Name of employer: ___________________________________________________ Address (No. & street, city, zip code) _____________________________________ ___________________________________________________________________ Telephone number: ( ) ______________County: _________________ Name of petitioner, if not the employer: ___________________________________ Address (No. & street, city, zip code) _____________________________________ ___________________________________________________________________ Telephone number: ( ) ______________County: _________________ Name of representative, if any, to whom correspondence is to be directed: ___________________________________________________________________ Address (No. & street, city, zip code) _____________________________________ ___________________________________________________________________ Telephone number: ( ) ______________ Identify any currently recognized or certified negotiating agent or any other employee organization(s) which may be affected by this petition. Name: _____________________________________________________________ Address: ___________________________________________________________ ___________________________________________________________________ Name: _____________________________________________________________ Address: ___________________________________________________________ ___________________________________________________________________ 3. 4. 5. American LegalNet, Inc. www.FormsWorkFlow.com 6. (a) Describe the negotiating unit(s) which may be affected by the petition. Include job titles and classifications, and number of employees in such unit(s). (b) Attach a copy of the most recent contract for the negotiating unit(s). 7. Set forth a clear and concise statement of the details of and the reasons for the proposed clarification or placement. Include the job title and classification, job description and number of employees in each position which is the subject of the petition. I declare that I have read the above Petition and that the statements herein are true to the best of my knowledge and belief. ________________________________ Petitioner By: __________________________ Signature of representative filing petition ________________________________ Title (if any) ( ) _______________________ Dated: __________________________ PERB 576 (1/14) American LegalNet, Inc. www.FormsWorkFlow.com