Form Nlrb 502 – Fill Out and Use This PDF

INSTRUCTIONS: Submit an original of this Petition to the NLRB Regional Office in the Region in which the employer concerned is located.

The Petitioner alleges that the following circumstances exist and requests that the NLRB proceed under its proper authority pursuant to Section 9 of the NLRA.

1.PURPOSE OF THIS PETITION (if box RC, RM, or RD is checked and a charge under Section 8(b)(7) of the Act has been filed involving the Employer named herein, the statement following the description of the type of petition shall not be deemed made.) (Check One)

RC-CERTIFICATION OF REPRESENTATIVE - A substantial number of employees wish to be represented for purposes of collective bargaining by Petitioner and Petitioner desires to be certified as representative of the employees.

RM-REPRESENTATION (EMPLOYER PETITION) - One or more individuals or labor organizations have presented a claim to Petitioner to be recognized as the representative of employees of Petitioner.

RD-DECERTIFICATION (REMOVAL OF REPRESENTATIVE) - A substantial number of employees assert that the certified or currently recognized bargaining representative is no longer their representative.

UD-WITHDRAWAL OF UNION SHOP AUTHORITY (REMOVAL OF OBLIGATION TO PAY DUES) - Thirty percent (30%) or more of employees in a bargaining unit covered by an agreement between their employer and a labor organization desire that such authority be rescinded.

UC-UNIT CLARIFICATION- A labor organization is currently recognized by Employer, but Petitioner seeks

clarification of placement of certain employees:

(Check one)

In unit not previously certified.

In unit previously certified in Case No.

AC-AMENDMENT OF CERTIFICATION- Petitioner seeks amendment of certification issued in Case No.

Attach statement describing the specific amendment sought.

2.

Name of Employer

Employer Representative to contact

Tel. No.

3.

Fax No.

Address(es) of Establishment(s) involved (Street and number, city, State, ZIP code)

4a.

Type of Establishment (Factory, mine, wholesaler, etc.)

4b. Identify principal product or service

Cell No.

e-Mail

5.

Unit Involved (In UC petition, describe present bargaining unit and attach description of proposed clarification.)

6a. Number of Employees in Unit:

Included

Present

Proposed (By UC/AC)

Excluded

6b. Is this petition supported by 30% or more of the

employees in the unit?*

Yes

No

(If

you have checked box RC in 1 above, check and complete EITHER item 7a or 7b, whichever is applicable)

*Not applicable in RM, UC, and AC

7a.

Request for recognition as Bargaining Representative was made on (Date)

and Employer declined

recognition on or about (Date)

(If no reply received, so state).

7b.

Petitioner is currently recognized as Bargaining Representative and desires certification under the Act.

8. Name of Recognized or Certified Bargaining Agent (If none, so state.)

Affiliation

Address

Tel. No.

Date of Recognition or Certification

Fax No.

e-Mail

Cell No.

9. Expiration Date of Current Contract. If any (Month, Day, Year)

10.

If you have checked box UD in 1 above, show here the date of execution of

agreement granting union shop (Month, Day and Year)

11a.

Is there now a strike or picketing at the Employer's establishment(s)

11b. If so, approximately how many employees are participating?

Involved?

Yes

No

11c.

The Employer has been picketed by or on behalf of (Insert Name)

, a labor

organization, of (Insert Address)

Since (Month, Day, Year)

12.Organizations or individuals other than Petitioner (and other than those named in items 8 and 11c), which have claimed recognition as representatives and other organizations and individuals known to have a representative interest in any employees in unit described in item 5 above. (If none, so state)

Name

Address

Tel. No.

Fax No.

Cell No.

e-Mail

13. Full name of party filing petition (If labor organization, give full name, including local name and number)

14a. Address (street and number, city, state, and ZIP code)

14b. Tel. No.

EXT

14c. Fax No.

14d. Cell No.

14e. e-Mail

15. Full name of national or international labor organization of which Petitioner is an affiliate or constituent (to be filled in when petition is filed by a labor organization)

I declare that I have read the above petition and that the statements are true to the best of my knowledge and belief.

Name (Print)

Signature

Title (if any)

Address (street and number, city, state, and ZIP code)

Tel. No.

Fax No.

Cell No.

eMail

WILLFUL FALSE STATEMENTS ON THIS PETITION CAN BE PUNISHED BY FINE AND IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001)

PRIVACY ACT STATEMENT

Solicitation of the information on this form is authorized by the National Labor Relations Act (NLRA), 29 U.S.C. § 151 et seq. The principal use of the information is to assist the National Labor Relations Board (NLRB) in processing unfair labor practice and related proceedings or litigation. The routine uses for the information are fully set forth in the Federal Register, 71 Fed. Reg. 74942-43 (Dec. 13, 2006). The NLRB will further explain these uses upon request. Disclosure of this information to the NLRB is voluntary; however, failure to supply the information will cause the NLRB to decline to invoke its processes.