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	
COMPLAINT
(Pursuant to §§ 111.06, 111.70(3), or 111.84, Stats.)
	
Complete and submit the original and two (2) copies of this form, together with the required $100 filing fee. 	
IDENTITY OF PARTIES INVOLVED
(all information is mandatory)	
Name of Complainant	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	
				
What are the facts which constitute the alleged unfair labor or prohibited practice(s)?  (Attach additional pages if needed)	
	
What part or parts of the applicable statute defining unfair labor or prohibited practice(s) are alleged to have been violated?  (Attach additional pages if needed)	
	
What remedy do you seek?  (Attach additional pages if needed)	

I declare that I have read the contents of this complaint and that the statements it contains are true and correct to the best of my knowledge.
	
Complainant’s Signature		Date