Case No.
Date Filed
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)
(if checked, complete sections 26 - 28 & 29, skip sections 23-25)
20. Name of Grievant and Brief Statementof the Dispute: 21. Number of Employee in Unit:
22. Brief Statement of the Remedy Sought:
23. Employer's Representative Name 24. Signature /s/ 25. Date
26. Labor Organization's Rep.'s Name 27. Signature /s/
28.. Date
I hereby certify that I have served a copy of this Petition on the representative of the opposing party.
Method of Service
In hand First Class Mail Other (specify): ___________________
Signature and Title of Person making Certification /s/
DLR FORM_ARB1 Revised 06/15
801 CMR 4.00 (456) 1. The filing fee for an application for public sector grievance arbitration filed pursuant to M.G.L. Chapter 150, §6 is
$1,000; 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.
2. The filing fee for an application for private sector grievance arbitration filed pursuant to M.G.L. Chapter 150, §6 is $1,500; 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
PETITION TO INITIATE GRIEVANCE ARBITRATION
DEPARTMENT OF LABOR RELATIONS
