PREVIEW ONLY - No response can be submitted.
Request to Start a Union
Contact Information
Please provide your name and a way for someone to contact you about your request.
Employee Contact
*
Your full name.
Phone Number
*
(xxx) yyy-zzzz
Mailing Address
What street address or PO Box can you be reached at by mail?
City
State
*
Please select...
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
Email Address
*
Your email will only be used to respond to your request.
Employer Information
Please tell us basic information about your employer. This section is required.
Employer Name
*
The name of the company where you work.
Location
*
(i.e., customer service, mailroom, loading dock, intensive care, school)
Address
*
Physical address of your worksite. (i.e., 100 Industrial Ave)
City
*
State
*
Please select...
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip
*
Employer Type
*
Private
Public
Industry
*
Please select...
select one
Building & Construction Trades
Education
Healthcare
Manufacturing
Service
Other
In what industry do you work?
Please Specify
No. Employees
*
Roughly how many employees are in your unit?
Do any units/locations of this company have a union?
*
Yes
No
Other organized units or locations
If you answered yes to the last question, please fill in the following information as best you can.
Union Name
Which union?
Unit or Location
What's the unit/location the union represents?
Union History
Please tell us about past union activity at your location.
Elections
Yes
No
Has a there ever been a union election?
Date of Election
mm/dd/yyyy
Result of Election
Yes Vote
No Vote
What was the outcome?
Union(s) Involved
Workforce Description
Please describe for us as best you can the makeup of the workforce at your worksite. This information is optional but can be useful in the event of an organizing drive.
Male
Percentage that is male.
Female
Percentage that is female.
African-American
Percentage that is African-American.
Asian-American
Percentage that is Asian-American.
Caucasion
Percentage that is caucasian.
Hispanic
Percentage that is Hispanic.
Native American
Percentage that is Native-American.
Other
Percentage that is some other ethnic group.
Wages & Benefits
Please tell us about wages and benefits for workers at your unit/location.
Paid How Often
Please select...
every week
every 2 weeks
every month
When do you get paid?
Payday
What day do you get paid?
Overtime
Over 8hrs / Day
Over 40hrs / Week
Ineligible for OT
When do you qualify for OT?
Shift
1st shift
2nd shift
3rd shift
hours vary
What shifts are available?
Paid Leave
sick leave
vacation
holidays
parental
death
What kind of paid leave options are available?
Health Benefits
medical
dental
vision
mental
life insurance
Check all that apply.
Health Costs
Yes
No
Do you pay a premium for your health benefits?
Workplace Issues
Tell us what are the major issues or problems at your worksite? At least one issue is required.
Issue 1
*
Examples could be unsafe working conditions, low wages, discrimination, favoritism, high healthcare costs, low wages, poor or no benefits, etc.
Issue 2
Issue 3
Additional Comments
Is there anything else you would like us to know?
Comments
Need assistance with this form?
