Alliance System Federation
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 Brotherhood of Maintenance of Way Employees Division
Alliance System Federation

1085 West State St.
Alliance OH, 44601
(330) 680-4100


Time Limits start on the date of occurrence (violation). Submit this form as soon as possible to insure time limits are met. Information in this form will be used to develop a written claim or grievance. Please fill out the entire form to ensure accuracy and provide as much detail as possible.

TO: *
(Designated Carrier Officer to Receive Claim)
Date: *

WHO is claiming?

Claimant Name *
ID # *
Address *
City *
State *
Zip *
Phone (1) *
Phone (2)
Phone (3)
Headquarters *
Gang No. *
Position *
Work Hours
A.M.
A.M. to
*
P.M.
P.M.
Choose one *
Seniority dates:
Position
Date
Position
Date
Position
Date
Present Position: *
Working
Furloughed
Adjustment Requested:
ST Hrs =
OT Hrs =
DT Hrs =
List any additional claimants:
Name
Employee No
Seniority Date
Position
Pay Rate
Name
Employee No
Seniority Date
Position
Pay Rate
Name
Employee No
Seniority Date
Position
Pay Rate
Name
Employee No
Seniority Date
Position
Pay Rate
Name
Employee No
Seniority Date
Position
Pay Rate
List any witnesses:
WHAT did the company specifically do that violated the Agreement? (Who, What, When, Where) *
WHAT rule(s) do you feel were violated? *
Who is being claimed? *
ID # *
Assigned Position
Seniority Date *
Headquarters
Regular Assigned Hours
WHEN did the violation occur? *
Date(s) of violation *
Time: (From) *
(To) *
Total hours involved *
Is this claim/violation continuing? *
WHERE did the violation occur? *
Location (M.P.) *
Station/Yard *
Seniority District *
Division *
Town *
State *
IF THIS IS A CONTRACTING OUT VIOLATION: *
Name of Contractor
Number of Contractor’s employees
Time worked each day
Date(s) worked
Type of equipment used:
Explain what the contractor was doing
I hereby authorize my Representative to make resolution of this claim
Signature *

Use your mouse, finger, or touch device to write your signature.
Lodge # *
Employee ID # *
Additional Information






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Alliance System Federation
1085 West State St.
Alliance, OH 44601
  1-330-680-4100

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