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Joint Request For Certification Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Joint Request For Certification, PERA-1, Pennsylvania Workers Comp,
JOINT REQUEST FOR
CERTIFICATION
DO NOT WRITE IN THIS SPACE
IN THE MATTER OF THE EMPLOYES OF:
CASE NO.
DATE FILED
TO THE HONORABLE, THE MEMBERS OF THE PENNSYLVANIA LABOR RELATIONS BOARD:
The Petition of the employe organization and the public employer herein respectfully sets forth:
EMPLOYE ORGANIZATION INFORMATION
___________________________________________________________________________________________________________
Employe Organization
Contact Name
___________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________
City
State
Zip
Telephone
PUBLIC EMPLOYER INFORMATION
___________________________________________________________________________________________________________
Public Employer
Contact Name
___________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________
City
1.
State
Zip
Telephone
The public employer has agreed to recognize the employe organization pursuant to Section 602(a) of the Public Employe Relations
Act based on a determination that a majority of the employes in the proposed unit desire to be represented by the employe
organization; said determination is based upon:
________________________________________________________________________________________________________.
(state method used to determine the desire of the majority of employes)
2.
Description of the unit deemed to be appropriate:
Included:
Excluded:
3.
Approximate number of employes in the unit claimed to be appropriate: _____
PERA-1 REV 5-09 (Page 1)
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4.
5.
The proposed unit includes:
Nonprofessional employes only
Professional employes only
Professional and nonprofessional employes
(refer to §604(2) of the Act)
Security guards only (refer to §604(3) of the Act)
Prison guards only (refer to §604(3) of the Act)
First level supervisors (refer to §604(5) of the Act)
There are no other employe representatives claiming to represent any of the employes in the proposed unit except
(if applicable):
________________________________________________________________________________________________________
Name
Telephone
________________________________________________________________________________________________________
Address
City
State
Zip
6.
The public employer has posted the five-day notice pursuant to 34 Pa. Code § 95.11(8) AND HAS ATTACHED PROOF OF
POSTING.
7.
Other relevant facts: _______________________________________________________________________________________
________________________________________________________________________________________________________
WHEREFORE, Petitioners request that the Pennsylvania Labor Relations Board pursuant to Section 602(a) of the Public Employe
Relations Act approve the proposed unit as appropriate and certify the employe organization as the exclusive representative for all
employes in the unit.
_______________________________________________________________
Petitioner – Employe Organization
_______________________________________________________________
Petitioner – Public Employer
By _______________________________________________
By _______________________________________________
Signature
Signature
_________________________________________________
Printed Name
Title
_________________________________________________
Address
_________________________________________________
Printed Name
Title
_________________________________________________
Address
_________________________________________________
City
State
Zip
_________________________________________________
Telephone
_________________________________________________
City
State
Zip
_________________________________________________
Telephone
INCOMPLETE OR INACCURATE STATEMENTS MAY RESULT IN A DISMISSAL OF THIS PETITION.
FAILURE TO FILE ORIGINAL AND THREE (3) COPIES OF THE PETITION MAY CAUSE A DELAY IN 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
PERA-1 REV 5-09 (Page 2)
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