COMMONWEALTH OF MASSACHUSETTS
DO NOT WRITE IN THIS SPACE
DIVISION OF LABOR RELATIONS
Case No. Date Filed
PETITION FOR CERTIFICATION
BY WRITTEN MAJORITY AUTHORIZATION
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 as amended by Chapter 120 of Acts of 2007.
1. Name of Employer 2. Representative to contact 3. Telephone Number
4. Address (street and no., city/town, state, and ZIP code) 5. Fax Number
6. Full description of the bargaining unit including job titles 7. No. of employees in Unit
(attached additional sheets if necessary)
Included 8. Does the proposed
bargaining unit comply with
of the provisions of
M.G.L. 150E. §3 and
Excluded 456 CMR 14.07?
Yes No
9. Does the petitioner certify that no other employee organization has been and currently is lawfully recognized as the
exclusive representative of the employees in the appropriate bargaining unit? Yes No
10. Has the employee organization received a written majority authorization, as described in 456 CMR 11.09 and 11.10,
from a majority of the employees in the proposed appropriate bargaining unit?
Yes No
11. Name of Petitioner 12. Representative to contact 13. Telephone Number
14. Address (street and no., city/town, state, and ZIP code) 15. Fax Number
* * * Questions 16 and 17 relate only to Petitions filed pursuant to M.G.L. c.150E * * *
16.
Has the Petitioner complied with the filing requirements of M.G.L. 150E §§ 13 and 14?
17. Last Date of Filing
Yes No
DECLARATION
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 or type) Signature Title (if any)
Address (street and no., city/town, state, and ZIP code) Telephone Number
CERTIFICATE OF SERVICE
I hereby certify that I have served a copy of this Petition on the following representative(s) of the opposing party.
Employer
Name Address (street and no., city/town, state, and ZIP code)
Telephone Number
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-WMA1 (page 1)
ADA Coordinator (617) 626-7132. This document is available in alternative formats. Revised 12/07
