Statement Of Occurrance

Local
Local Telephone Number
Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Work Location
Seniority Date / MM / DD YYYY
Work Telephone Number
Home Telephone Number
Department
Supervisor's Name
Supervisor's Phone Number
The Following is a statement of what happen to me on
Action was in violation of article
Please Describe below
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I hereby give 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.
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