UNITED STATES OF AMERICA NATIONAL LABOR RELATIONS BOARD DO NOT WRITE IN THIS SPACE INSTRUCTIONS: Unless e-Filed using the Agency's website, , submit an original of this Petition to an NLRB office in the Region in which the employer concerned is located. The petition must be accompanied by both a showing of interest (see 6b below) and a certificate of service showing service on the employer and all other parties named in the petition of: (1) the petition; (2) Statement of Position form (Form NLRB-505); and (3) Description of Representation Case Procedures (Form NLRB 4812). The showing of interest should only be filed with the NLRB and should not be served on the employer or any other party. 1. PURPOSE OF THIS PETITION: RC-CERTIFICATION OF REPRESENTATIVE - A substantial number of employees wish to be represented for purposes of collective bargaining by Petitioner and Petitioner desires to be certified as representative of the employees. 2a. Name of Employer: 2b. Address(es) of Establishment(s) involved (Street and number, City, State, ZIP code): 3a. Employer Representative - Name and Title: 3b. Address (if same as 2b - state same): 3c. Tel. No. 3d. Cell No. 3e. Fax No. 3f. E-Mail Address (Factory, mine, wholesaler, etc.) 5a. City and State where unit is located: 6a. Number of Employees in Unit: 6b. Do a substantial number (30% or more) of the employees in the unit wish to be represented by the Petitioner? Yes No Check One: 7a. Request for recognition as Bargaining Representative was made on (Date) and Employer declined recognition on or about (Date) (If no reply received, so state). 7b. Petitioner is currently recognized as Bargaining Representative and desires certification under the Act. 8a. Name of Recognized or Certified Bargaining Agent (If none, so state) 8c. Tel. No. 8d. Cell No. 8e. Fax No. 8f. E-Mail Address (Month, Day, Year) 9. Is there now a strike or picketing at the Employer's establishment(s) involved? If so, approximately how many employees are participating? (Name of Labor Organization) , has picketed the Employer since (Month, Day, Year) 10a. Name 10b. Address 10c. Tel. No. 10d. Cell No. 10e. Fax No. 10f. E-Mail Address Manual Mail Mixed Manual/Mail 11a. Election Type: 12a. Full Name of Petitioner (including local name and number): 12b. Address (street and number, city, State and ZIP code): (if none, so state): 12d. Tel. No. 12e. Cell No. 12f. Fax No. 12g. E-Mail Address 13. Representative of the Petitioner who will accept service of all papers for purposes of the representation proceeding. (street and number, city, State and ZIP code): 13c. Tel. No. 13d. Cell No. 13e. Fax No. 13f. E-Mail Address I declare that I have read the above petition and that the statements are true to the best of my knowledge and belief. Name (Print) Signature Title DateWILLFUL FALSE STATEMENTS ON THIS PETITION CAN BE PUNISHED BY FINE AND IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001) PRIVACY ACT STATEMENT Solicitation of the information on this form is authorized by the National Labor Relations Act (NLRA), 29 U.S.C. § 151 www.nlrb.gov/