STATEMENT OF OCCURRENCE

LOCAL  LOCAL NUMBER 

 NAME 

 ADDRESS 

 WORK LOCATION 

 SENIORITY DATE  NCS DATE 

 WORK TELEPHONE NO.  HOME TELEPHONE NO. 

 DEPARTMENT  TITLE 

 SUPERVISORíS NAME  PHONE NO. 

 ††††††††††††††† GIVE COMPLETE STATEMENT OF FACTS CONCERNING THE GRIEVANCE CONDITION THAT EXISTS

The following is a statement of what happened to me on  which action was in violation of Article  

Of the Working Agreement.

 
_


SIGNED GRIEVANT  DATE  


I hereby give consent to the inspection by any authorized Union Representative of any records kept by the Company whichAffect the conditions of my employment, which may include Security Reports, Medical Records or Opinions. Police 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  DATE  


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