18. List any Employee Organization(s) (other than the Petitioner and the Employee Organization listed in question 9, if any)
known to have an interest in representing the employees in the Unit
Name Address (street and no., city/town, state, and ZIP code) Telephone Number
19. Name of Petitioner 20. Representative to contact 21. Telephone Number
22. Address (street and no., city/town, state, and ZIP code) 23. Fax Number
24. If the Petitioner is an Employee organization, has the Petitioner complied with the 24a. Last Date of Filing
filing requirements of M.G.L. c.150E, §§13 and 14?
Yes No
I have read the above petition and swear under the pains and penalties of perjury that the information contained in it is
true and complete to the best of my knowledge and belief.
Name (print) Signature Title (if any)
Address (street and no., city/town, state, and ZIP code) Telephone Number
I hereby certify that I have served a copy of this Petition on the following representative(s) of the opposing partie(s).
Name Address (street and no., city/town, state, and ZIP code)
Method of Service
In hand First Class Mail Other (specify): ___________________
Name Address (street and no., city/town, state, and ZIP code)
Method of Service
In hand First Class Mail Other (specify): ___________________
Signature of Person making Certification Telephone Number
The Division does not discriminate on the basis of disability in access to its services. Inquiries, complaints or requests,
including requests for auxiliary aids and information regarding access features should be directed to the LRC FORM-003 (page 2)
ADA Coordinator (617) 626-7132. This document is available in alternative formats. Revised 11/07
CERTIFICATE OF SERVICE
DECLARATION
Telephone Number
Employer
* * * Questions 24 and 24a relate only to Petitions filed pursuant to M.G.L. c.150E * * *
Telephone Number
Incumbent Employee Organization (if any)
