Revised 05/09/2018
HUMAN RESOURCES DEPARTMENT
500 W. Markham - Suite 130W - Little Rock, Arkansas 72201-1428
(501) 371-4590 FAX (501) 371-4496
www.littlerock.gov
DISCIPLINARY ACTION APPEAL HEARING REQUEST
FOR NON-UNIFORM EMPLOYEES
To request a disciplinary action appeal hearing, you must meet eligibility requirements and do so within ten (10)
days from receipt of the disciplinary action (City of Little Rock’s Personnel Policy and Procedure Manual, V- 4.1).
Please complete this form and submit it to the Human Resources Department.
I, ______________________________________, request a hearing to appeal the following disciplinary action:
(Employee Name)
Written Reprimand (AFSCME only) Suspension
Termination Demotion
Date Disciplinary Action Was Received: ____________________________________________
A copy of the disciplinary action is / is not attached. (Circle one)
Employee's Home Address: ______________________________________________________
_____________________________________________________________________________
Employee's Home Telephone Number: _____________________________________________
Employee's Email Address: ______________________________________________________
___________________________________________ __________________________
Employee's Signature Date
NOTE TO EMPLOYEE REQUESTING APPEAL: You have the right to have a union steward, attorney,
or other representative to represent you. If you plan to have a representative, you must provide the name,
address and telephone number of your representative to the Human Resources Department within ten (10)
days from receipt of the disciplinary action. If you obtain representation after this timeframe, the hearing
will not be rescheduled to accommodate his/her attendance. You have the right to review all material the
Department used to base their decision to take this action against you and receive a list of witnesses to be called at
the hearing. The department will contact you when the information is ready to be picked up. The information can
only be picked up by you. You will have to sign a statement designating receipt of materials.
I WILL BE REPRESENTED BY THE FOLLOWING INDIVIDUAL: Union Representative
___________________________________________ __________________________ Attorney
Name Telephone Number
Other (Please Specify)
_______________________________________________________________________
Address
Please coordinate with this individual for scheduling.
