Grievance Submission Form

Grievance Submission Form for Members at St. John Pleasant Valley and Regional

If you have an issue on the job that you feel violates our contract, please fill out this form and contact your steward or Union Representative. There are time limitations on grievance filings so it is extremely important that you contact your Union representative when submitting this form.

Member Name

Title

First Name *

Last Name *

Suffix

Home Address

Address 1 *

Address 2

City

State / Province / Region

Postal Code

Country

Personal Email Address

Phone Number

- ###

#### *

Employer / Shift

* 'Employer / Shift' is required

Facility Site

* 'Facility Site' is required

Supervisor

* 'Supervisor' is required

Length of Employment

* 'Length of Employment' is required

Work Phone

'Work Phone' is required

Rate of Pay

* 'Rate of Pay' is required

Statement of Complaint or Grievance

Settlement Desired

Date

* 'Date' is required

Signature

Please type your full name here in lieu of your signature.

* 'Signature' is required