Fillable PETITION FEDERAL LABOR RELATIONS AUTHORITY (FLRA)

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PETITION FEDERAL LABOR RELATIONS AUTHORITY (FLRA)

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The PETITION FEDERAL LABOR RELATIONS AUTHORITY (FLRA) form is 1 page long and contains:

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See instructions on the back of this form. Attach additional sheets if needed, numbered according to the item to which they pertain. By signing the petition
form, a labor organization/petitioner certifies it has submitted to the agency or activity and to the Department of Labor a roster of its officers and
representatives, a copy of its constitution and by-laws, and a statement of its objectives.
UNITED STATES OF AMERICA
FEDERAL LABOR RELATIONS AUTHORITY
PETITION
FOR FLRA USE ONLY
10. I DECLARE THAT I HAVE READ THIS PETITION AND THAT THE STATEMENTS IN IT ARE TRUE TO THE BEST OF MY KNOWLEDGE AND
BELIEF. I UNDERSTAND THAT MAKING WILLFULLY FALSE STATEMENTS CAN BE PUNISHED BY FINE AND IMPRISONMENT, 18 U.S.C.
1001. THIS PETITION WAS SERVED ON ALL PARTIES KNOWN TO BE AFFECTED BY ISSUES RAISED IN THIS PETITION.
_________________________________ ___________________
_____________ ___________________________
Type or Print Your Name Your Signature Date
Case No.
Date Filed
1. Clear and concise statement of the purpose of the petition and the issues raised by the petition.
2. Description of the unit(s):
Included:
Excluded:
3. Approximate number of employees in the
unit(s) affected by issues raised in the petition.
Currently
Proposed
4. The petition is supported by:
___ a showing of interest of not less than 30%
___ evidence of membership of not less than 10%
of the employees in the unit(s) involved in the
petition.
5. PETITIONER:
NAME AFFILIATION / ADDRESS
(Street and Number, PHONE NO.
DEPARTMENT
City, State, and ZIP Code)
A. Petitioner
B. Petitioner Contact
6. AGENCY(IES), OTHER THAN PETITIONER, AFFECTED BY THE PETITION:
NAME DEPARTMENT ADDRESS
(Street and Number, PHONE NO.
City, State, and ZIP Code)
A. Activity/Agency
B. Activity/Agency Contact
A. Labor Organization
B. Labor Organization Contact
8A. Date(s) of Recognition/Certification (Month, Day and Year) of any unit(s)
affected by issues raised in the petition.
8B. Expiration of Current Agreement(s) (Month, Day and Year) covering
any unit(s) affected by issues raised in the petition.
9. Name, title, address, and telephone number of person filing petition.
7. LABOR ORGANIZATION(S), OTHER THAN PETITIONER, AFFECTED BY THE PETITION:
NAME AFFILIATION ADDRESS
(Street and Number, PHONE NO.
City, State, and ZIP Code)
OMB Control No. 3070-0003
Approved through 3/31/99
FLRA Form 21(Rev. 3/96)
OVERVIEW:
Use this form if you want to file a petition pursuant to Sections 7111, 7112 and 7115 of the Federal Service Labor
Management Relations Statute. Refer to the Rules and Regulations of the Federal Labor Relations Authority (FLRA), Part 2422 of 5
C.F.R., for additional information on how to file a petition. An original and two (2) copies of a petition must be filed with the appropriate
Regional Director, FLRA, along with a statement of any relevant facts not contained in the petition and a copy of all relevant
correspondence relating to matters raised by the petition. If you do not know the address of the Regional Director, you may contact the
Office of the General Counsel, FLRA, in Washington, D.C. at (202) 482-6600. Upon filing the petition, you must serve a copy of the
petition and accompanying materials on all affected parties. If additional space is needed, you may attach additional sheets numbered
according to the item to which they pertain. The showing of interest and alphabetical list of names constituting such showing, as required
by the Statute and the FLRA's Regulations for any petition seeking an election or petition seeking a determination for dues allotment, must
be filed with the petition, but may not be furnished to any other party.
PURPOSE OF THE PETITION AND STANDING TO FILE:
(
A)
Only a labor organization may file a petition to request: (1) an election to determine if employees in an appropriate unit wish to be
represented for the purpose of collective bargaining by an exclusive representative, and/or (2) a determination of eligibility for dues
allotment in an appropriate unit without an exclusive representative.
(B)
Only an individual may file a petition to request an election to determine if employees in a unit no longer wish to be represented for
the purpose of collective bargaining by an exclusive representative.
Petitions for the purposes described in
(A) or (B)
must be accompanied by a showing of interest or evidence of membership, as
appropriate.
(C)
An agency or a labor organization, or an agency and a labor organization jointly, may file a petition:
(1) to clarify or amend: (i) a recognition or certification then in effect (for example, to change the name or affiliation of the recognized or
certified exclusive representative or the name of the agency; or to resolve questions related to the eligibility of employees for inclusion in
the unit); and/or (ii) any other matter relating to representation (for example, to resolve representation questions related to a reorganization
or realignment of agency operations or issues related to the majority status of the currently recognized or certified labor organization); or
(2) to consolidate two or more units, with or without an election, in an agency and for which a labor organization is the exclusive
representative.
LINE BY LINE INSTRUCTIONS:
1. Provide a clear and concise statement of the purpose of the petition, the issues raised by the petition, and the results the petitioner
seeks.
2. Describe the unit(s) affected by issues raised in the petition. If the petitioner is seeking an election to determine the exclusive
representative of an appropriate unit of employees and/or a determination for dues allotment, the description should include the
geographic location and classifications of the employees sought to be included in, or sought to be excluded from, the unit. If the petitioner
is seeking an election to determine if employees no longer wish to be represented for purposes of collective bargaining by an exclusive
representative or to clarify, amend or consolidate existing units, the petitioner should provide a description of the existing certification(s) or
recognition(s). If more than one unit is affected, attach additional sheets.
3. State the approximate number of employees in the existing unit or the unit claimed to be appropriate; in a clarification or amendment,
state the approximate number of employees in the units affected by issues raised in the petition.
4. State whether a petition seeking an election is accompanied by a showing of interest of 30% of the employees in the unit claimed to be
appropriate. State whether a petition for a determination for dues allotment is accompanied by evidence of membership of 10% of the
employees in the unit claimed to be appropriate.
5. Provide the name and mailing address for the petitioner and the contact person, including street and number, city, state and zip code. If
a labor organization petitioner is affiliated with a national organization, provide the local designation and the national affiliation. If an activity
or agency is affiliated with an executive department, provide the name of the department.
6. Provide the name and mailing address for each activity or agency other than the petitioner affected by issues raised in the petition,
including street and number, city, state and zip code. Also provide the name, mailing address and work telephone number of the contact
person for each activity or agency affected by issues raised in the petition. If an activity or agency is affiliated with an executive department,
provide the name of the department.
7. Provide the name and mailing address for each labor organization other than the petitioner affected by issues raised in the petition,
including street and number, city, state and zip code. If a labor organization is affiliated with a national organization, provide the local
designation and the national affiliation. Provide the name, mailing address and work telephone number of the contact person for each
labor organization affected by issues raised in the petition.
8. If the labor organization(s) named in #7 is an exclusive representative of any of the employees affected by issues raised in the petition,
provide the date(s) of the recognition or certification and the date(s) any collective bargaining agreement covering the unit(s) will expire, or
the most recent agreement did expire, if known.
9. State the name, title and mailing address of the person filing the petition, including street and number, city, state and zip code and
telephone number .
10. Type or print the name of the person filing the petition. The person filing the petition must also sign and date the petition before it is
filed.
It is estimated that it will take one hour or less to complete this form. This petition is not valid unless an OMB control number is displayed on the form.
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PETITION FEDERAL LABOR RELATIONS AUTHORITY (FLRA)

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Completed 10 August 2020

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