First Name (required)
Last Name (required)
Last four digits of SS Number (required)
ID Number (required)
Home/Mailing Address (required)
Apartment/Unit Number
City (required)
State (required)
Zip Code (required)
Home Phone Number
Cell Phone Number (required)
Personal (Non-work) E-Mail Address (required)
Employing Agency (required)
Assignment (required)
Rank (required)
Division/District/Unit (required)
Work Hours (required)
Shift/Days Off (required)
Immediate Supervisor (required)
-- Please select the applicable description of your issue --Departmental InvestigationGrievanceOtherWill
Date of Incident (required)
Did the incident occur while you were on-duty or off-duty? (required) —Please choose an option—On-DutyOff-Duty
Please enter the charges against you (if known).
Please list the names of all individuals who could potentially be a witness against you. (if known)
Upload any notices or documentation relevant to the situation for which you are seeking representation.
Is this a Grievance? (required) —Please choose an option—YesNo
Date that you discovered the violation. (required)
Please list the Contract Article(s) you believe have been Violated. (required)
Please provide a brief explanation of the issue. (required)
INITIAL IN THE BOX BELOW. (required)
here, and agree to work cooperatively with my PBA Attorney or attorney in the handling of this matter.
Member Signature (Type Full Name):
Today's Date (MM/DD/YYYY):