FORM LM-15A
REPORT ON SELECTION OF
U.S. Department of Labor
Form approved
Office of Labor-Management
Office of Management
Standards
Washington, DC 20210
DELEGATES AND OFFICERS
This report is mandatory under P.L. 86-257, as amended. Failure to comply may result in criminal prosecution, fines,
and Budget
No. 1245-0003
Expires 09-30-2021
For Official Use Only
or civil penalties as provided by 29 U.S.C. 461.
TO ACCOMPANY TRUSTEESHIP REPORT, FORM LM-15, OR TERMINAL TRUSTEESHIP REPORT, FORM LM-16
READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS REPORT
1. File Number of Labor Organization Held in Trusteeship
3. Labor Organization Held in Trusteeship
P.O. Box, Building and Room Number, if any
Affiliation or Organization Name
Number and Street
Designation (Local, Lodge, etc.)
Designation Number (Prefix/Number/Suffix)
City
State
Unit Name (if any)
ZIP Code + 4
Part A - Selection of Delegates Complete Part A if during the reporting period a convention or other policy-determining body met to which the trusteed labor
organization sent delegates or would have sent delegates if not in trusteeship. (If the answer to any of the questions in Part A is "No", provide details in Item 20.)
8. How were the delegates nominated?
4. Describe the convention or other policy determining body:
a. At a membership meeting
a. Name of body
b. By written nomination
c. By petition
b. Location(s)
d. Other
c. Type of body
9. Was every "member in good standing" eligible to be a
candidate (subject to reasonable qualifications uniformly
d. Date(s) of meetings
10. How was the membership notified of the date, time and,
place of the election?
Yes
No
5. Was the trusteed organization represented?
a. Mail notice
6. Did the delegates from the trusteed organization participate in the business of the convention
or other policy-determining body in the same manner as other delegates?
b. Posting at work site
c. Union newspaper
d. Other
7. How were the delegates from the trusteed organization selected?
11. Was every "member in good standing" eligible to vote (subject
a. Appointed by trustee
to reasonable qualifications uniformly
b. Elected by the membership
c. Other
Complete Items 8 through 12 only if Item 7.c is checked.
Signatures
Each of the undersigned, duly authorized officials of the labor organization imposing the trusteeship over the above labor organization, declares, under penalty
of perjury and other applicable penalties of law, that all of the information submitted in this report (including the information contained in any accompanying
documents) has been examined by the signatory and is, to the best of the undersigned's knowledge and belief, true, correct, and complete. (See the section
on penalties in the instructions.)
President
23. Signed
Trustee
21. Signed
(if other title,
(if other title,
see instructions.)
see instructions.)
On
On
Telephone Number
Date Date
Telephone Number
Treasurer
24. Signed
22. Signed
Trustee
(if other title,
(if other title,
see instructions.)
see instructions.)
On
On
Date
Telephone Number
Date
Telephone Number
Form LM-15A (2003)
Yes
No
Yes
No
Yes
No
Yes
No
2. Period Covered
Through:
By This Report
Month/Day/Year
( mm/dd/yyyy )
Month/Day/Year
( mm/dd/yyyy )
imposed)?
12. Was the election held by "secret ballot"?
imposed)?
Title
Title
Title
Title
From:
