Free F418-023-000 app for copies of citation & notice - Washington

Department of Labor and Industries WISHA Services PO Box 44638 Olympia WA 98504-4638

APPLICATION FOR COPIES OF CITATION AND NOTICES

Any employee of an employer who has been selected by the employees of that employer to act may apply for copies of CITATION AND NOTICES issued to said employer. DEFINITION: "Employee representative" means: a) b) c) Any officer of the recognized bargaining unit of employees, acting on behalf of the employees of the employer Any employee representative of an employer-employee safety committee within an establishment of the firm of the employer. Any employee of an employer who has been selected by the employees of that employer to act as their representative Such selection shall be evidenced by a letter or other written communication to the Division of WISHA Services stating the name of the employee so selected and signed by not less than one-half of the employees of the employer.

Applicant certifies he/she is an employee representative.
CERTIFICATION: Date I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE. Position Signature

Name and address of applicant to which copies of CITATION AND NOTICES should be sent:

Name, address, Labor & Industries account I.D., and Unified Business Identifier of EMPLOYER HAVING EMPLOYEES WHO ARE REPRESENTED by the applicant (please give full information for each employer you represent - use extra paper if required):

The director or his/her authorized representative may deny this application if more than one employee representative has applied or if the applicant does not qualify as an employee representative.
For Department Use Only

Application Rcv'd __________________ Applicant Notified__________________ Comment:

Application Granted by________________ Expiration Date ____________________

Date Application Granted______________________

F418-023-000 app for copies of citation and notice 9-04