Fillable Nlrb-505, 2015, Statement Of Position Form (Page 3 of 3) in pdf

FORM NLRB-5081

NATIONAL LABOR RELATIONS BOARD

(3-11)

QUESTIONNAIRE ON COMMERCE INFORMATION

Please read carefully, answer all applicable items, and return to the NLRB Office.

If additional space is required, please add a page and identify item number.

CASE NAME

CASE NUMBER

1. EXACT LEGAL TITLE OF ENTITY (As filed with State and/or stated in legal documents forming entity)

2. TYPE OF ENTITY

(Specify)

CORPORATION

LLC

LLP

PARTNERSHIP

SOLE PROPRIETORSHIP

OTHER

3. IF A CORPORATION OR LLC

A. STATE OF INCORPORATION OR FORMATION B. NAME, ADDRESS, AND RELATIONSHIP (e.g. parent, subsidiary) OF ALL RELATED ENTITIES

4. IF AN LLC OR ANY TYPE OF PARTNERSHIP, FULL NAME AND ADDRESS OF ALL MEMBERS OR PARTNERS

5. IF A SOLE PROPRIETORSHIP, FULL NAME AND ADDRESS OF PROPRIETOR

6. BRIEFLY DESCRIBE THE NATURE OF YOUR OPERATRIONS (Products handled or manufactured, or nature of services performed)

7A. PRINCIPAL LOCATION

7B. BRANCH LOCATIONS

8. NUMBER OF PEOPLE PRESENTLY EMPLOYED

A. TOTAL

B. AT THE ADDRESS INVOLVED IN THIS MATTER

9. DURING THE MOST RECENT (Check the appropriate box):

CALENDAR

12 MONTHS or

FISCAL YEAR

FY DATES

YES

A. Did you provide services valued in excess of $50,000 directly to customers outside your State?

If no, indicate actual value.

B. If you answered no to 9A, did you provide services valued in excess of $50,000 to customers

in your State who purchased goods valued in excess of $50,000 from directly outside your State?

If no, indicate the value of any such services you provided.

C. If you answered no to 9A and 9B, did you provide services valued in excess of $50,000 to public utilities, transit

systems, newspapers, health care institutions, broadcasting stations, commercial buildings, educational institutions,

or retail concerns? If less than $50,000, indicate amount.

D. Did you sell goods valued in excess of $50,000 directly to customers located outside your State?

If less than $50,000, indicate amount.

E. If you answered no to 9D, did you sell goods valued in excess of $50,000 directly to customers

located inside your State who purchased other goods valued in excess of $50,000 from directly

outside your State? If less than $50,000, indicate amount.

F. Did you purchase and receive goods valued in excess of $50,000 from directly outside your State?

If less than $50,000, indicate amount.

G. Did you purchase and receive goods valued in excess of $50,000 from enterprises who received

the goods directly from points outside your State? If less than $50,000, indicate amount.

H. Gross Revenues from all sales or performance of services (Check the largest amount):

If less than $100,000, indicate amount.

$100,000

$250,000

$500,000

$1,000,000 or more

I. Did you begin operations within the last 12 months? If yes, specify date:

10. ARE YOU A MEMBER OF AN ASSOCIATION OR OTHER EMPLOYEE GROUP THAT ENGAGES IN COLLECTIVE BARGAINING?

(If yes, name and address of association or group

YES

11. REPRESENTATIVE BEST QUALIFIED TO GIVE FURTHER INFORMATION ABOUT YOUR OPERATIONS

NAME

TITLE

E-MAIL ADDRESS

TEL. NUMBER

12. AUTHORIZED REPRESENTATIVE COMPLETING THIS QUESTIONNAIRE

NAME AND TITLE

SIGNATURE

E-MAIL ADDRESS

DATE

PRIVACY ACT STATEMENT

Solicitation of the information on this form is authorized by the National Labor Relations Act (NLRA), 29 U.S.C. § 151 et seq. The principal use of the information is to assist

the National Labor Relations Board (NLRB) in processing representation and/or unfair labor practice proceedings and related proceedings or litigation. The routine uses for

the information are fully set forth in the Federal Register, 71 Fed. Reg. 74942-43 (Dec. 13, 2006). The NLRB will further explain these uses upon request. Disclosure of this

information to the NLRB is voluntary. However, failure to supply the information may cause the NLRB to refuse to process any further a representation or unfair labor practice

case, or may cause the NLRB to issue you a subpoena and seek enforcement of the subpoena in federal court.