FORMName of Employer___     _ _                    _ Phone (),_                           ___ _Include Area Code)Name of Local Union                                                         _ Phone (                                                                                      Statement of Grievance: List what happened, where, when , why. Also, any contract violation.Adjustment  or  Settlement  Requested: (To be completed  by  Union)I authorize the Union to act for me in the disposition of this grievance and authorize the employer to release any information requested by the Union regarding this grievance.x    _  _ 
x_         _       Signature of Gr evant                                                                               Signature of  Local Union  Representative                                                                                                                     DateName of Employer  Representative who handled the grievance at the following steps:Verbal   Step_     _      1st  Written  Step                                   2nd Written Step                        __  _ Employer’s Answer to 1st Written Step: if grievance is denied, give reasons and proofs.Employer’s Answer to 2nd Written Step:{j)­(!)n3:l 0 (I)zc3cr(…I.)..X—–s=;gnature o..t,..E..m,,-p.,.oyer -R=e-presentat:ive——NOTICE TO LOCAL UNION – Make 3 Copies: (1) Employer, (2) Union, (3) Local Union. Be sure to send all proofs and evidence to the Union office along with Grievance.1