CHARGE OF UNFAIR LABOR PRACTICE(S) UNDER THE PENNSYLVANIA LABOR RELATIONS ACT AND ACT 111 DO NOT WRITE IN THIS SPACE ________________________________________________ COMPLAINANT v. CASE NO. DATE FILED _______________________________________________________ RESPONDENT TO THE HONORABLE, THE MEMBERS OF THE PENNSYLVANIA LABOR RELATIONS BOARD: COMPLAINANT INFORMATION ________________________________________________________________________________________________________________________ Employe, Employe Organization or Employer ________________________________________________________________________________________________________________________ Name of Person filing charge on behalf of Complainant Title ________________________________________________________________________________________________________________________ Address ________________________________________________________________________________________________________________________ City State Zip ________________________________________________________________________________________________________________________ Telephone HEREBY CHARGES THAT RESPONDENT INFORMATION ________________________________________________________________________________________________________ Employer, Employe Organization or Employe alleged to have committed unfair labor practice(s) ________________________________________________________________________________________________________ Address ________________________________________________________________________________________________________ City State Zip ________________________________________________________________________________________________________ Telephone HAS ENGAGED IN UNFAIR LABOR PRACTICE(S) CONTRARY TO THE PROVISIONS OF THE PENNSYLVANIA LABOR RELATIONS ACT, SECTION 6 AS FOLLOWS: Choose one: subsection (1) subsection (2) Choose all that apply: clause (a) clause (b) clause (c) clause (d) clause (e) clause (f) Check here if more than one respondent and list on separate sheet. Check here if a grievance relating to this issue has been filed and enclose three (3) copies of the grievance and one (1) copy of the Collective Bargaining Agreement to assist in review of this charge. FAILURE TO ENCLOSE THESE DOCUMENTS WILL CAUSE A DELAY IN PROCESSING. PLRB-15 REV 5-09 (Page 1) American LegalNet, Inc. www.FormsWorkflow.com SPECIFICATION OF CHARGES Set forth all of the events alleged to constitute the unfair labor practice(s). Include specific facts, dates, names, addresses, place of occurrence, and other relevant facts. If additional space is needed, please continue on additional sheet(s). WHEREFORE, the Complainant respectfully requests the Pennsylvania Labor Relations Board to enter the charge upon the Docket of the said Board and to issue and cause to be served upon the Respondent above named a Complaint stating the charge(s) of unfair labor practice(s). COMMONWEALTH OF PENNSYLVANIA COUNTY OF : : : ss On this __________ day of____________________, 20_____, before me, a ______________________________, in and for said County and State, personally appeared ______________________________ who being duly sworn according to law, deposes and says that he/she is the person filing the foregoing CHARGE OF UNFAIR LABOR PRACTICE(S) and is aware of the contents hereof and that the matters and facts set forth herein are true and correct to the best of his or her knowledge, information and belief. SWORN AND SUBSCRIBED TO before me the day and year first aforesaid. ________________________________________________ ________________________________________________ Signature of Notary Signature of Complainant or Representative FAILURE TO FILE AN ORIGINAL AND THREE (3) COPIES OF THE CHARGE AND ALL ACCOMPANYING EXHIBITS MAY DELAY PROCESSING. Pennsylvania Labor Relations Board | 651 Boas Street, Room 418 | Harrisburg, PA 17121-0750 717.787.1091 | Fax 717.783.2974 | www.dli.state.pa.us PLRB-15 REV 5-09 (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkflow.com