Petition Form, Form 1351d

• Legal Form Number: 1351d
• Section: Office of Congressional Workplace Rights (United States)

advancing workplace rights, safety and health, and accessibility in the legislative branch

OfficeofCongressionalWorkplaceRights

OCWR Form 1351d

Room LA-200, John Adams Building · 110 Second Street, SE · Washington, DC 20540-1999 · t/202.724.9250 · f/202.426.1913

www.ocwr.gov

1

LABOR MANAGEMENT – PETITION FORM

See instructions below. Attach additional sheets if needed, numbered according to the

box(es) below to which they pertain.

By signing the petition form, a labor organization petitioner certifies that it has submitted

to the employing office or activity and to the Department of Labor a roster of its officers

and representatives, a copy of its constitution and bylaws, and a statement of its

objectives.

FORM 1351d

DO NOT WRITE IN THIS SPACE

Case No.

Date Filed

1. Clear and concise statement of the purpose of the petition and the issues raised in the petition:

2.Description of the unit(s):

Included:

Excluded:

3. Approximate number of employees inthe unit(s) affected by the

petition:

Currently:

Proposed:

4. The petition is supported by:

___ a showing of interest ofnotless than 30%.

evidence of membership ofnot less than 10%of the

employees in the unit(s) involved in the petition.

5. Petitioner:

5A. Petitioner name: Address: Tel. #: Ext.

E-mail:

5B. Petitioner contact name: Address: Tel. #: Ext.

E-mail: