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    LOCAL: CWA 3176 CONTACT NUMBER: 407-604-1724

    First Name *
    Last Name *
    Home Address *
    City *
    State *
    Zip Code *
    Personal Email *
    Personal Home Number *
    Personal Cell Number *
    Your Employer *
    Employee ID Number *
    Job title or titles *
    Work Department or group
    Original Hire Date
    Union Seniority Date
    Work Address *
    Work City *
    Supervisor Name *
    Supervisor Email Address *
    Supervisor Contact Number *
    Grievance Statement


    The following is a statement of what happened to me on

    Date of Violation or Incident *
    Full Statment *
    NOTE: This section must be filled out in complete detail of what occurred as this statement can be read by an arbitrator to understand the intent of the employee filing the grievance.
    File Uploads
    NOTE: This section can be used to upload photos or other documents that can support the processing of the grievance.
    NOTE: This field can be used to list any witnesses that can support the grievance. The witness should include thier name, contact number, and an email addres.
    Signature Statement
    I hereby give written consent to the inspection by any authorized Union Representative of any records kept by the Company which may affect the conditions of my employment, which may include Security Reports, Medical Records or Opinions, Police Reports, 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. I also attest that the signature below is in accordance with the E-SIGN act of 2000.
    Signature Date *
    Printed Signature Name *
    Signature *

    Use your mouse, finger, or touch device to write your signature.

  • CWA Local 3176

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