* * * * * * * * * * Request for Represention:Full Legal Name:*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Email:* Enter Email Confirm Email Government Email:* Personal Cell Phone #:*Work Cell #:*Position / GS-Series: (EG: 1801 / 0083 / 0080 / 1811)*Grade: (Ex: GS-5, 9, 11, 12, 13)*Are you a member of a Bargaining Unit?*Date of hire under your current position?* MM slash DD slash YYYY Bargaining Unit of DHS (FPS or CISA? )*FPSCISAWhere is your duty station (City State).*Who is your first line supervisor?*Please answer the following Questions in narrative so we can best assist you:Who is Involved?*What Happened?*Where did the Event/Incident Happen?*When did the Event/Incident Happen?* MM slash DD slash YYYY Why do you believe this happen?*How (if applicable)Please state the potential violation of Law, Rule, Regulation, Policy, or Contract Provision (or advise you don’t know of one):*Have you taken any legal action or filed anything concerning or related to this request for representation / assistance? (Ex: EEO, MSPB, OIG, OSC) if Yes, Please explain:*Is there anyone who may be an officer or steward of the Union that you believe may have a conflict of interest concerning you or your potential case (If yes, please state who and why) This question is asked to provide you the best representation we can taking into account concerns you may have. This information must be shared with at least one of the Following: President, Executive Vice President, Secretary, Treasurer of National Local 918.*Did you ever have or currently have a personal attorney or representative for this or any other current or ongoing employment related issue(s)? If yes, please explain:*Remedy: What are you seeking to be made whole? or what are you seeking from the Union on your behalf?*Consent* I agree to the privacy policy.I, do hereby 1.) Designate AFGE National Local # 918 and / or its representative(s) assigned by the Executive Chief Union Steward, President, Executive Vice President or Secretary/Treasurer of AFGE National Local # 918 to perform representational functions in my name and on my behalf, in all and any matters pertaining to or affecting my employment as a federal employee. 2.) As my representative(s), AFGE National Local 918 is authorized to receive copies of all correspondence, documents, and material pertaining to or affecting my employment as a federal employee. 3.) Said designation(s) shall remain in effect until revoked by me personally, in writing, or until the immediate necessity for representation has been concluded, whichever occurs first. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
