PETITION UNDER THE PENNSYLVANIA LABOR RELATIONS ACT OR ACT 111 OF 1968 IN THE MATTER OF THE EMPLOYES OF: DO NOT WRITE IN THIS SPACE CASE NO. DATE FILED PETITION FOR REPRESENTATION – Petitioner seeks investigation of a question of representation and certification of representative designated or selected for the purpose of collective bargaining by the employes in an appropriate unit; SIGNED AND DATED SHOWING OF INTEREST MUST BE ATTACHED (refer to § 7(c) of the Pennsylvania Labor Relations Act and 34 Pa. Code §§ 91.1 et seq.). JOINT REQUEST FOR CERTIFICATION – The employer recognizes the employe representative and agrees that the unit set forth in Item #1 below is appropriate and that the employe representative has the necessary support from the employes as required by law; petition has been posted for a period of five (5) days in work locations of the employes in the bargaining unit (AFFIDAVIT CERTIFYING POSTING MUST BE ATTACHED); employer and employe representative MUST SIGN joint request. PETITION FOR DECERTIFICATION – Thirty (30) percent or more of the employes assert that the certified bargaining representative is no longer their representative (SIGNED AND DATED SHOWING OF INTEREST MUST BE ATTACHED) or the employer alleges a good faith doubt of the majority status of the present representative (FACTUAL SUPPORT MUST BE ATTACHED). PETITION FOR UNIT CLARIFICATION – An employe organization is currently recognized by the employer and petition seeks clarification of existing unit certified at Case No.________________________________________________________ (if applicable). PETITION FOR AMENDMENT OF CERTIFICATION – Petitioner seeks amendment of certification issued in Case No. _________________________________________ ; STATEMENT DESCRIBING THE SPECIFIC AMENDMENT SOUGHT MUST BE ATTACHED. EMPLOYER INFORMATION ________________________________________________________________________________________________________ Employer Contact Name ________________________________________________________________________________________________________ Address ________________________________________________________________________________________________________ City State Zip Telephone EMPLOYE ORGANIZATION INFORMATION ________________________________________________________________________________________________________ Employe Organization Contact Name ________________________________________________________________________________________________________ Address ________________________________________________________________________________________________________ City 1. State Zip Telephone Description of the unit deemed to be appropriate (in Petitions for Unit Clarification, describe present unit below and attach description of proposed clarification and reason(s) for the request): Included: Excluded: 2. Approximate number of employes in the unit claimed to be appropriate: Present: _____ PLRB-13 REV 5-09 (Page 1) Proposed by Unit Clarification Petition: _____ American LegalNet, Inc. www.FormsWorkflow.com 3. There are no other employe representatives claiming to represent any of the employes in the proposed unit except (if applicable): _____________________________________________________________________________________________________ Name _____________________________________________________________________________________________________ Address _____________________________________________________________________________________________________ City State Zip Telephone 4. Date of expiration of current agreement (if any): _______________________________________________________________________ 5. Other relevant facts: I declare that I have read the above petition and that the statements therein are true to the best of my knowledge and belief. ________________________________________________ ________________________________________________ (Petitioner and Affiliation, if any) (Petitioner and Affiliation, if any) By_______________________________________________ By ______________________________________________ Signature Signature ________________________________________________ Printed Name Title ________________________________________________ Address ________________________________________________ Printed Name Title ________________________________________________ Address ________________________________________________ City State Zip ________________________________________________ Telephone ________________________________________________ City State Zip ________________________________________________ Telephone INCOMPLETE OR INACCURATE STATEMENTS HEREON 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 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program PLRB-13 REV 5-09 (Page 2) American LegalNet, Inc. www.FormsWorkflow.com