1. Employer's Name 2. Telephone Number
3. Employer's Address (street and no., city/town, state, and zip code) 4. Fax Number
5. Employer's Labor Relations Representative 6. Email Address 7. Telephone Number
8. Employer's Representative's Address (street and no., city/town, state, and zip code) 9. Fax Number
10. Labor Organization's Name 11. Telephone Number
12. Labor Organization's Address (street and no., city/town, state, and zip code) 13. Fax Number
14. Labor Organization's Representative's Name 15. Email Address 16. Telephone Number
17. Address (street and no., city/town, state, and zip code) 18. Fax Number
19 This Petition is being filed by: (check one)
Jointly (If checked, complete sections 23 through 28 and skip section 29)
Employer Only (if checked, complete sections 23 - 25 & 29, skip sections 26-28)
Labor Org. Only (if checked, complete sections 26 - 28 & 29, skip sections 23-25)
20. Name of Grievant and Brief Statementof the Dispute:
21. Brief Statement of the Remedy Sought:
22. Employer's Representative Name 22. Signature /s/ 24. Date
25. Labor Organization's Rep.'s Name 26. Signature /s/ 27.. Date
I hereby certify that I have served a copy of this Petition on the representative of the opposing party.
In hand First Class Mail Other (specify): ___________________
Signature and Title of Person making Certification /s/
DLR FORM_OGM1 Revised 06/15
801 CMR 4.02 (456) (3) The filing fee for an application for grievance mediation filed pursuant to M.G.L. c. 150, § 6 is $300; provided,
however, that the fee shall be paid in equal shares by the party seeking application and the answering party; provided, further, that the
Director of the Department of Labor Relations may, where appropriate, provide for the waiver of the filing fee for any particular
controversy or classes of controversies.
DO NOT WRITE IN THIS SPACE
COMMONWEALTH OF MASSACHUSETTS
REQUEST FOR GRIEVANCE MEDIATION
DEPARTMENT OF LABOR RELATIONS
