Joint Request for Certification of Exclusive Repre

Joint Request for Certification of Exclusive Representative

Please complete the form below. Note that fields marked with an asterisk (*) are required. Once the form has been submitted, you will receive an e-mail response with a copy of all data submitted. If this is a joint petition, forward the confirmation e-mail to the other party. If you have any questions while completing the form, contact 651-649-5421 or mediation.services.bms@state.mn.us.

Is the Employer a Private or Public organization?	*	Public Private
The undersigned petitioner requests that the Minnesota Bureau of Mediation Services investigate the above referenced matter and resolve such in accordance with applicable state law (Minn. Stat. Chapter 179 and 179A).

Name of UNION	*
UNION Address	*
City	*	St* Zip*
Name of REPRESENTATIVE	*
Check if the following information is the same as above:	*	Yes No
REPRESENTATIVE Address
City		St Zip
Daytime Phone	*	Ext.
Cell Phone
E-Mail Address	*
Check if the following information is the same as above:	*	Yes No
Name of LEGAL COUNSEL/CONSULTANT (if any)
COUNSEL/CONSULTANT Address
City		St Zip
Daytime Phone		Ext.
Cell Phone
E-Mail Address

Name of EMPLOYER	*
EMPLOYER Address	*
City	*	St* Zip*
Name of REPRESENTATIVE	*
Check if the following information is the same as above:	*	Yes No
REPRESENTATIVE Address
City		St Zip
Daytime Phone	*	Ext.
Cell Phone
E-Mail Address	*
Check if the following information is the same as above:	*	Yes No
Name of LEGAL COUNSEL/CONSULTANT (if any)
COUNSEL/CONSULTANT Address
City		St Zip
Daytime Phone		Ext.
Cell Phone
E-Mail Address

Name, address, phone number and e-mail address of any other employee organization having an interest in or claiming to represent any of the employees affected by this Petition.

Type of Employer	*
Number of employees covered by this request	*
Description of PROPOSED Unit	*

AUTHORIZATION CARDS SUBSTANTIATING MAJORITY SUPPORT MUST BE SUBMITTED TO THE BUREAU OF MEDIATION SERVICES BY MAIL, FAX OR HAND DELIVERY BEFORE THIS PETITION WILL BE PROCESSED. BE CERTAIN TO IDENTIFY THE EMPLOYER WHEN SUBMITTING THE CARDS.
THIS IS A JOINT PETITION WHICH IT WILL NOT BE PROCESSED BY THE BUREAU OF MEDIATION SERVICES UNTIL WE RECEIVE WRITTEN CONFIRMATION FROM THE NON-SUBMITTING PARTY(S). WRITTEN CONFIRMATION CAN BE SENT FROM THE OTHER PARTY(S) BY FORWARDING THIS E-MAIL TO MEDIATION.SERVICES.BMS@STATE.MN.US
THE UNDERSIGNED AFFIRM THAT THE EMPLOYEE DOES, IN FACT, REPRESENT MORE THAN 50% OF THE EMPLOYEES IN THE APPROPRIATE UNIT.
A COPY OF THE CURRENT CONSTITUTION AND BY-LAWS (UNLESS PREVIOUSLY SUBMITTED) MUST ACCOMPANY THIS PETITION. IF YOU ARE UNABLE TO UPLOAD A FILE, THEY MAY BE FAXED, MAILED OR HAND DELIVERED.
FAX: 651-643-3013
MAIL: 1380 ENERGY LANE, SUITE 2, ST. PAUL, MN 55108
QUESTIONS: 651-649-5421
Upload Constitution and By-Laws
NOTE: Once the Petition has been submitted online, do NOT mail, fax or e-mail the original.

Date of Petition:	*
Name of Person Filing this Petition	*	Title
E-Mail Address of Person Filing this Petition	*