Grievance Form
                                                                      
                                  Communication Workers of America
                                                        Local 9431

                              161 Palm Avenue, Suite 1, Auburn, California 95603
                                         Phone: 530-823-9431 Fax: 530-823-0239

(This form to be filled out by the Grievant and will be sent to the Union Steward; be sure to read
the  paragraph at the bottom of the page.) (Important: Sign and date the form accordingly.)
 Please Print Legibly 

Grievantís Name:____________________     Supervisor:___________________________

Job Title:______________________     Shift:______  Pay Rate:______________________

NCS Date:_________________                       Occurrence Date:_____________________

Home Address___________________    Work Address:___________________________

_________________________________              ________________________________

Phone:________________________     Phone or V.M_____________________________

E-Mail: ______________________________ _   Pager:____________________________

Statement Of Grievance:___________________________________________________

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Attach additional Pages if necessary:
 By Submitting this you authorize any certified CWA representative to have copies of any of your records that may
affect your condition of employment. This includes medical records or opinions, security reports or any  records
necessary and relevant to protect your rights under the collective bargaining agreement and any labor laws that apply


 
Signed___________________________________         Date:__________________