STATEMENT OF OCCURRENCE

                MEMBER

NAME _________________________   ADDRESS _________________________

WORK LOCATION _______________    HOME/CELL TEL#___________________

SENIORITY DATE _______________    WORK TEL# _______________________

DEPARTMENT __________________    TITLE ____________________________

SUPERVISOR'S NAME ________________________________________________

            The following is a statement of what happened to me on ______________________________

                                                                                                            (Date)

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Grievant(s) Name:

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             (Printed)                                          (Signed)