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	

PETITION FOR REFERENDUM TO DETERMINE THE CONTINUATION OF A 
FAIR SHARE AGREEMENT INVOLVING TRANSIT OR PUBLIC SAFETY EMPLOYEES
(Pursuant to § 111.70(2), Stats.)

Complete and submit this form together with the original showing of interest document.

The Initiating Party requests the Wisconsin Employment Relations Commission to conduct a referendum among the employees in the collective bargaining unit described below to determine whether the required number of such employees favor the continuation of the fair share agreement existing between the Municipal Employer and the Labor Organization named below and to certify the results thereof.

At least thirty (30) percent of the employees in the collective bargaining unit set forth below desire a referendum to determine whether the fair share agreement shall continue as supported by the confidential showing of interest which is submitted in support of this petition.

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	
				
Describe the Collective Bargaining Unit With Inclusions and Exclusions	
	
Describe the Fair Share Agreement Involved	
	
Information regarding the collective bargaining agreement containing the fair share agreement existing between the parties:	
Date Executed		Date Effective		
Date May be Reopened		Date Expires		
Date Most Recent Referendum (if any) Was Conducted		
Results of Most Recent Referendum: 	
  Continuance
  Discontinuance	

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