Petition for Grievance Mediation

STATE OF MICHIGAN

MICHIGAN EMPLOYMENT RELATIONS COMMISSION

MEDIATION DIVISION

PETITION FOR GRIEVANCE MEDIATION

INSTRUCTIONS: COMPLETE THIS PETITION USING THIS WEBFORM, YOU MUST INCLUDE THE NAME, EMAIL AND CONTACT NUMBER FOR EACH PARTY REPRESENTATIVE. EMAIL CONFIRMATION OF THIS WEB FORM WILL BE SENT TO ALL PARTIES.

Employer is Public Private

Mediation Request is Filed by Union Employer Worker/Employee

Party 1: Employer

Employer Name

Address

Address (continued)

City

State

Zip code

Employer Website

Employer Representative for Grievance Mediation

First Name

Last Name

Title/Position

Contact Email

Cell Phone

Union/Labor Organization Information

Union/Labor Organization Full Name

Union/Labor Organization Short Name or Acronym

Address

Address (continued)

City

State

Zip code

Union/Labor Organization Representative for Grievance Mediation

First Name

Last Name

Title/Position

Contact Email

Cell Phone

Grievance Information

Grievance Mediation Authority CBA Provision Other Written Agreement Other

Date Grievance Filed

Internal Grievance No.

Grievance Category (e.g., Termination, Seniority Violation etc.)

FAST TRACK MEDIATION, if possible (Checking this box indicates the agency will attempt to conduct a virtual mediation session within 72 hours of initiating this matter. Fast Track Mediation

Person Filing This Petition

First Name

Last Name

Title/Position

Contact Email

Cell Phone

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Petition for Grievance Mediation

Petition for Grievance Mediation

STATE OF MICHIGAN

MICHIGAN EMPLOYMENT RELATIONS COMMISSION

MEDIATION DIVISION

PETITION FOR GRIEVANCE MEDIATION

Party 1: Employer

Employer Representative for Grievance Mediation

Union/Labor Organization Information

Union/Labor Organization Representative for Grievance Mediation

Grievance Information

Person Filing This Petition