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April 27, 2024

Standing with our Community

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Local Officers
Mississippi (LPAT)
Statement of Occurrence
Contract Book

Statement of Occurrence

Local Number

CWA Local 3509 Phone Number

First and Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Seniority Date

Month

Day

Year

NCS Date

Month

Day

Year

Personal Cell

Personal Address

Department

Title

Supervisor's Name

Supervisor's Cell

GIVE COMPLETE STATEMENT OF FACTS CONCERNING THE GRIEVANCE CONDITION THAT EXISTS

Type Signature

Date

Month

Day

Year

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.

If you can’t get to form to work, click the link to download a fillable form. Statement of Occurrence word doc

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CWA Local 3509

Standing with our Community

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Home
Local Officers
Mississippi (LPAT)
Statement of Occurrence
Contract Book