Form NMB-1 Application for Investigation of Representation Dispute

Form NMB - 1 OMB No. 3140-0001 (Expiration Date 7/31/2016)

Application for Investigation of Representation Dispute

Date: _________________________________

TO THE NATIONAL MEDIATION BOARD, Washington, D. C. 20005: A dispute has arisen among the employees of:

Name of Carrier:		Address:
Contact:		City, State, Zip Code:
Telephone Number:		Fax Number:
E-Mail

as to who is the representative of these employees designated and authorized in accordance with the requirements of the Railway Labor Act. The undersigned, one of the parties to the dispute, hereby requests the National Mediation Board to investigate this dispute, and to certify the name or names of the individuals or organizations authorized to represent the employees involved in accordance with Section 2, Ninth, of the Act.

PARTIES TO DISPUTE

Petitioning organization or representative:
Organization holding existing agreement, if any:	Date:
Other organization or representatives involved in dispute:

CRAFT OR CLASS of Employees Involved – (If more than one craft or class, use a separate application)

	Craft or Class	Number of Employees

Federal Law prohibits knowingly and willfully making materially false, fictitious, or fraudulent statements or representations in any matter within the jurisdiction of the U.S. Government. 18 U.S.C. § 1001. This includes the information provided on this application as well as the accompanying showing of interest.

EVIDENCE OF REPRESENTATION – this application is supported by:

At least 50%

I declare that the information submitted is true to the best of my knowledge

Name and Signature:
Title:
Address:		Telephone:
City, State, Zip Code:		Fax:
E-Mail

Instructions: Continue to page 2.

Form NMB - 1 OMB No. 3140-0001 (Expiration Date 06/30/2016)

Application for Investigation of Representation Dispute

APPLICANT NOTICE OF APPEARANCE

The ______________________________________________ hereby enters the following names, addresses,

(Applicant Organization)

phone numbers, fax numbers, and email addresses for the individual(s) designated as the representative(s)

of ______________________________________________ in connection with the Application for Investigation

(Applicant Organization)

of Representation Dispute:

Name & Title:		Telephone:
Address:		Fax:
City, State, Zip Code		Email:
		Alternate Telephone:

Name & Title:		Telephone:
Address:		Fax:
City, State, Zip Code		Email:
		Alternate Telephone:

Name & Title:		Telephone:
Address:		Fax:
City, State, Zip Code		Email:
		Alternate Telephone:

Filing Instructions: File this application in duplicate. Additional Sheets: Use and attach additional sheets as needed.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control Number. The valid OMB control number for this information collection is 3140-0001. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

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