MASSACHUSETTS CIVIL SERVICE COMMISSION – /$<2)) APPEAL FORM
Name of
P
erson Filing Appeal Name of Government Agency
(Appellant):
That Laid You Off (Respondent):
Appellant Street or P.O.
Box: Respondent
Street or P.O. Box:
Appel
lant City, State, Zip Code: Respondent City, State, Zip Code:
Appellant Contact Phone Number: Respondent Contact Phone Number:
Appellant Email Address:
What was your most recent title or position?
When did you receive the written notice of decision regarding the layoff?
Are you alleging that the Respondent failed to provide you with proper bumping
and/or reinstatement rights?
(Yes / No)
Have you ever filed an appeal with the Civil Service Commission before?
REQUIRED NEXT STEPS BY APPELLANT
1. Attach a check or money order in the amount of $50.00 made payable to the Civil Service Commission.
2. Attach a copy of the written notice of decision that you received from the Respondent.
3. Mail or hand-deliver this appeal form to the Civil Service Commission at One Ashburton
Place: Room 503, Boston, MA 02108 within ten (10) business days of receiving the
notice of decision by the Respondent. (For those appeals received via mail, the postmark date will be
used to determine if the appeal is timely.)
4. Mail or hand-deliver a copy of this layoff appeal form to the Respondent.
WHAT HAPPENS AFTER THE COMMISSION RECEIVES YOUR APPEAL FORM?
1. Within ten (10) days, you and the Respondent will receive an Acknowledgment Form from
the Commission along with a “Notice of Pre-Hearing Conference”. The pre-hearing
conference is usually held within thirty (30) days from the time the Commission received
your appeal.
2. You and the Respondent are required to attend the Pre-Hearing Conference at which time a
member of the Commission will provide further details about how your appeal will proceed.
SIGNATURE OF APPELLANT:
TODAY’S DATE:
CSC Layoff Appeal Form Rev. 9/27/13
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signature
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