TEAMSTERS LOCAL NO. 63
Member's Record of Contract Violation
  Member's Record of Contract Violation to print select File -> Print then chick
TODAY'S DATE: _____________________________

NAME: _____________________________     SSN _______________________
ADDRESS _________________________________________________________________________
CITY/STATE ________________________________________________  ZIP _________________
HOME PHONE _______________________     WORK PHONE ______________________________

COMPANY: _________________________________________________________________
ADDRESS _________________________________________________________________________
CITY/STATE ______________________________________________________________________

CLASSIFICATION: _____________________________     HIRE DATE _______________________

NATURE OF GRIEVANCE/DISPUTE
DATE GRIEVANCE OCCURED: _________________________________
NATURE OF GRIEVANCE: ___________________________________________________________
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RELIEF REQUESTED/ACTION SOUGHT: ______________________________________________
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MEMBER SIGNATURE___________________________________
 

PLEASE DO NOT WRITE BELOW LINE - OFFICE USE ONLY

ARTICLE VIOLATED: _________________________________
NOTES: ___________________________________________________________
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CASE SETTLED: _____________   DATE _______________   AGENT ________________________
Print out and mail (do not fax or e-mail) completed form to:
845 Oak Park Road., Covina, CA 91724