TEAMSTERS LOCAL NO. 572
Sample Grievance Form

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 OCCURRED: _________________________________
NATURE OF GRIEVANCE: ___________________________________________________________
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RELIEF REQUESTED/ACTION SOUGHT: ______________________________________________
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MEMBER SIGNATURE___________________________________

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PLEASE DO NOT WRITE BELOW LINE - OFFICE USE ONLY

ARTICLE VIOLATED: _________________________________
NOTES: ___________________________________________________________
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CASE SETTLED: _____________ DATE _______________ AGENT ________________________

This is a SAMPLE only. To request a grievance form, contact your Shop Steward or the Local Union office at 450 E. Carson Plaza Drive Carson, CA 90746