STATEMENT OF OCCURRENCE


Local Local Telephone NO.


 NAME:   WORK ADDRESS: 


HOME ADDRESS: 


SENIORITY DATE:  NCS DATE: 


PERSONAL CELL:  PERSONAL EMAIL: 


DEPARTMENT:  TITLE: 


(GIVE COMPLETE STATEMENT OF FACTS CONCERNING THE GRIEVANCE CONDITION THAT EXISTS)


The following is a statement of what happened to me on,20, which action was in violation of Article  of the Working Agreement, and any other applicable Article(s), Section(s), Terms, or Conditions of the Collective Bargaining Agreement.



SIGNED GRIEVANT:  Date:


I hereby give consent to the inspection by authorized Union Representative of any records kept by the Company which may affect the conditions of my employment, which may include Security Reports, Medical Records or Opinions, Police Reports, Court Records or Reports, or any other information which may be relevant and necessary to allow the Union to protect my rights under the Working Agreement between the union and the Company. This authorization is given in accordance with the existing agreement between the Union and the Company.


SIGNED GRIEANT:  Date: 


LIST ANY WITNESS:  TITLE:  PHONE NO: 

                                               TITLE:  PHONE NO: 

                                               TITLE:  PHONE NO: 

                                               TITLE:  PHONE NO: 


SendSend