AFSCME LOCAL______________

STEP______________

OFFICIAL GRIEVANCE FORM

NAME OF EMPLOYEE___________________________DEPARTMENT_______________________________

CLASSIFICATION__________________________________________________________________________

WORK LOCATION________________________IMMEDIATE SUPERVISOR___________________________

TITLE____________________________________________________________________________________

STATEMENT OF GRIEVANCE:

List applicable violation:______________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Adjustment required:________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

I authorize the A.F.S.C.M.E. Local __________ as my representative to act for me in the disposition of this grievance.

Date____________________ Signature of Employee______________________________________________

Signature of Union Representative______________________________Title____________________________

Date Presented to Management Representative___________________________________________________

Signature_____________________________________________ Title________________________________

Disposition of Grievance: ____________________________________________________________________

_________________________________________________________________________________________

__________________________________________________________________________________

THIS STATEMENT OF GRIEVANCE IS TO BE MADE OUT IN TRIPLICATE. ALL THREE ARE TO BE SIGNED BY THE EMPLOYEE AND/OR THE AFSCME REPRESENTATIVE HANDLING THE CASE.

ORIGINAL TO_____________________________________________________________________________

COPY____________________________________________________________________________________

COPY: LOCAL UNION GRIEVANCE FILE

NOTE: ONE COPY OF THIS GRIEVANCE AND ITS DISPOSITION TO BE KEPT IN GRIEVANCE FILE OF  

            LOCAL UNION.

THE AMERICAN FEDERATION OF STATE, COUNTY AND MUNICIPAL EMPLOYEES                            F29