Fillable Unfair Labor Practice Charge 150A Charge 150A.PDF (Commonwealth of Massachusetts)

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Unfair Labor Practice Charge 150A Charge 150A.PDF (Commonwealth of Massachusetts)

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Case No. Date Filed
INSTRUCTIONS: Answer all applicable questions. Failing to provide information may result in the dismissal of the charge.
File an original and two (2) copies of this form with the Division.
1. Employer 2. Representative to contact 4. Telephone Number
3. Address (street and No., city/town, state, and ZIP code) 5. Fax Number
6. Employee Organization (if any): 7. Representative to contact 9. Telephone Number
8. Address (street and No., city/town, state, and ZIP code) 10. Fax Number
11. This charge is filed against (check one)
Employer Employee Organization
12. The above named employer or employee organization has engaged or is engaging in a prohibited practice within the
meaning of Massachusetts General Law, Chapter 150A, Section(s) (enter all appropriate sections/subsections)
Failing to specify an appropriate section/subsection may result in the dismissal of the charge.
13. Summary of basis of Charge (be specific as to names, dates, addresses, etc.) Attach additional sheets, documents and/or
affidavits if necessary. Please note: failure to allege specific facts may/will result in dismissal of the charge.
By these and other acts, the party complained of has interfered with, restrained, and/or coerced rights guaranteed by the Law.
14. Have you filed a charge concerning the same allegations with the
National Labor Relations Board? Yes No
DLR FORM-004 (page 1)
Revised 11/07
DO NOT WRITE IN THIS SPACE
DIVISION OF LABOR RELATIONS
CHARGE OF PROHIBITED PRACTICE
M.G.L. c.150A
COMMONWEALTH OF MASSACHUSETTS
15. (a) Is there a collective bargaining agreement that may apply to the conduct that is
alleged to have violated the Law? Yes No
(b) If you checked "Yes" in question 15(a), please list all of the clauses alleged to apply and attach a copy of each.
(c) Is there a grievance concerning this matter pending?
Yes No
16. Without limiting your rights to later amend your remedial request, please explain what remedy you seek. Include the
amount of any financial remedy to which you claim entitlement.
17. Have you attempted to settle this case?
If not, why not? Yes No
Note: The Division may decline to issue a complaint unless reasonable settlement efforts have been made by the charging party 456 CMR 15.04(1).
The Division may refer the charge to a Division mediator for settlement discussions.
18. Name 19. Representative to contact 21. Telephone Number
20. Address (street and No., city/town, state, and ZIP code) 22. Fax Number
23. The Charging Party is an:
Individual Employee Organization Employer
I have read the above charge of prohibited practice 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 Charge of Prohibited Practice on the following representative of the
opposing party.
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 DLR FORM-004 (page 2)
ADA Coordinator (617) 626-7132. This document is available in alternative formats. Revised 11/07
Telephone Number
CERTIFICATE OF SERVICE
DECLARATION
INFORMATION ON CHARGING PARTY
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Unfair Labor Practice Charge 150A Charge 150A.PDF (Commonwealth of Massachusetts)

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Completed 27 July 2020

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