State of Wisconsin
Employment Relations Commission
2418 Crossroads Drive, Suite 1000, Madison, WI  53718-7896
Phone:  608-243-2424    Fax:  608-243-2433
Email:  werc@werc.state.wi.us	

REQUEST FOR ANNUAL CERTIFICATION ELECTION
(Pursuant to ch. 111, Stats., and either Wis. Admin. Code ERC ch. 70, 71, or 80)

Complete and submit this form together with the applicable filing fee and any required original showing of interest. The required filing fee is determined by the number of eligible voters.  Please select the appropriate box below: 
	
 1-100 Eligible Voters = $200	 251-500 Eligible Voters = $500	 1,001-3,000 Eligible Voters = $1,500	
 101-250 Eligible Voters = $350	 501-1,000 Eligible Voters = $750	 3,001 or More Eligible Voters = $2,000	

The Labor Organization requests the Wisconsin Employment Relations Commission to conduct an annual certification election among certain general employees of the Employer named herein to determine whether those employees shall be represented by the Labor Organization for purposes of collective bargaining with the Employer and to certify to the parties the results of such election.
	
All Information is Required	
Name of Labor Organization	Name of Employer	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address 	Telephone No.	Email Address	
				
Name of Representative 	Name of Representative 	
		
Street Address, City, State, Zip Code (if different)	Street Address, City, State, Zip Code (if different)	
		
Telephone No.	Email Address 	Telephone No.	Email Address 	
				
Name of Representative (if needed) 	Name of Representative (if needed)	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address 	Telephone No.	Email Address 	
				
Describe the Collective Bargaining Unit with Inclusions and Exclusions	
	
Approximate Number of Employees in Bargaining Unit		
Select Applicable Statement:	
  The requester is the current exclusive collective bargaining representative for the bargaining unit.
  The requester is not the current exclusive collective bargaining representative for the bargaining unit.	
List the Name, Address, Telephone Number, and Email Address of Any Union Who Currently Represents the Employees Involved.	
	
Date Labor Organization Served a Copy of the Request on Employer.		

I declare that I have read the contents of this request and that the statements it contains are true and correct to the best of my knowledge.
	
Name		Title		
Signature		Date		

NOTICE TO EMPLOYER

The law requires that within ten (10) calendar days of its receipt of the election request, the employer shall provide: (1) the union with an electronic sortable list of the names of the employees the employer believes are eligible to vote in the election; and (2) the Wisconsin Employment Relations Commission with an electronic sortable list of said employees, their mailing addresses, and the last four digits ONLY of their social security numbers.