Case No. Date Filed
The petitioner hereby requests that the Division proceed under the authority of M.G.L. c.150E, Section 4 or
M.G.L. c.150A, Section 5(c).
1. Type of petition (Check One)
Petition by or on behalf of Municipal Employees seeking certification or decertification of an Employee Organization (MCR).
Petition by or on behalf of Employees of the Commonwealth seeking certification or decertification of an Employee
Organization (SCR)
Petition on behalf of a Municipal Employer seeking to resolve a claim of representation by one or more Employee
Organizations (MCRE).
Petition on behalf of the Commonwealth seeking to resolve a claim of representation by one or more Employee
Organizations (SCRE).
Petition by or on behalf of Private Employees seeking certification or decertification of an
Labor Organization (CR).
Petition on behalf of a Private Employer seeking to resolve a claim of representation by one or more Labor
Organizations (CRE).
2. Name of Employer 3. Representative to contact 4. Telephone Number
5. Address (street and No., city/town, state, and ZIP code) 6. Fax Number
7. Unit involved (attached additional sheets if necessary) 8a. No. of employees in Unit
Included
8b. Are any of the
employees included in the
Excluded unit currently represented?
Yes No
9. Name of incumbent Employee Organization 10. Telephone Number 11. Is the petition supported
by at least 50% of the
employees in the Unit?
12. Address (street and no., city/town, state, and ZIP code) 13. Fax Number
Yes No
16. If the incumbent
14 Date on which the incumbent Employee 15. Expiration date of most recent Employee Organization was
Organization was first Recognized or Certified collective bargaining agreement certified, Case No.
17. Is the petition supported by at least 30% of the employees in the Unit?
Yes No
DLR FORM-003 (page 1)
Revised 11/07
DO NOT WRITE IN THIS SPACE
COMMONWEALTH OF MASSACHUSETTS
REPRESENTATION PETITION
DIVISION OF LABOR RELATIONS
* * * If you checked "no" in question 8b, skip questions 9-16 and answer question 17 * * *
* * * If you checked "yes" in question 8b, answer questions 9-16 and skip question 17 * * *
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)