PART B - EMPLOYEE INFORMATION:
Name of Employee: The name of the "public employee," as defined in section 447.203(3), Florida Statutes, who desires to be a member of an employee organization that is either (1) certified to represent a bargaining unit that includes the public employee, or (2) seeking to become a certified bargaining agent for a prospective bargaining unit that includes the public employee.
Name of Public Employer: The public employer is one of the following, depending upon the type of public employment:
||Type of Employment
||State agency employee belonging to a statewide bargaining unit, and Correctional Education Program employees
|Board of Trustees (specify university)
||State University employee (includes New College)
|Board of Trustees (specify college)
||Community College employee
|District School Board (specify county)
||School District employee
|Board of Trustees of the Florida School for the Deaf and the Blind
||Florida School for the Deaf and the Blind academic and academic administrative personnel
|Political Subdivision or Agency thereof (specify subdivision)
||County, Municipality, Special District, or other political subdivision employee
Name of Agency: The state agency, or the political subdivision's agency, department, or other sub- unit that actually employs the public employee, if different from the listed "public employer." If the agency is the same as the "public employer," check the box to indicate this.
Class Title: The classification applicable to the employee used in the bargaining unit definition in the most recent Certification Order of the Public Employees Relations Commission, if any. If there is not an active bargaining unit certification applicable to the employee, the employee should list the class title assigned by the employer.
Class Code: The code, if any, assigned by the employer to the employee's classification. If there is no class code, check the box next to "Not Applicable."
PERC Form 2023-1.101, Effective July 1, 2023, Incorporated in R. 60CC-1.101