Petition for Mediation Services

Petition for Mediation Services
Please complete the form below. Once the form has been submitted, you will receive an e-mail response with a copy of all data submitted.

If you have any questions while completing the form, contact the Bureau at 651-649-5421.
Sector:*

PublicPrivateHospital
Petition Type:*

ContractGrievanceInterest-Based Collective Bargaining
For Interest Based Collective Bargaining, please complete our Request for Training/Faciliation form found here: https://form.jotform.com/230325786796065
If Grievance:

Required by ContractVoluntary Agreement to Mediate
Name of Employer:*
Full Name of Employer
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Employer Representative:*

First NameLast Name
Check here if address is the same as above:

Yes
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email*
example@example.com
Add Additional Employer Representative or Counsel?

Yes
Name of Additional Employer Representative:*

First NameLast Name
Check here if address is the same as above:

Yes
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email*
example@example.com
Name of Union:*
Full Name of UNION Organization. (Not an individual or representative name.)
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Union Representative or Counsel:*

First NameLast Name
Check here if address is the same as above:

Yes
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.
E-Mail Address:*
example@example.com
Add Additional Union Representative or Counsel?

Yes
Name of Additional Union Representative or Counsel:*

First NameLast Name
Check here if address is the same as above:

Yes
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.
E-Mail Address:*
example@example.com
Type of Employer:*
Bargaining Unit Type:*
Number of Employees in Unit:*
Number of Prior Negotiating Meetings Held:
Date of 1st Negotiating Meeting:

MonthDayYear
Date
Do not include name of Grievant if discipline related.
Remaining Contract Negotiation Issues -or-Concise Statement of Grievance:*
Expiration Date of Current Contract:*

MonthDayYear
Date
Check if first contract:
Date Petitioner Will Send Copy to Other Party(s):*

MonthDayYear
Date
Name of Person Filing Petition:*

First NameLast Name
E-Mail Address of Person Filing:*
example@example.com
Signature:*

Clear
Should be Empty:

Petition for Mediation Services

Please complete the form below. Once the form has been submitted, you will receive an e-mail response with a copy of all data submitted.

Do not include name of Grievant if discipline related.