Public Employment Relations Act Exemption Claim Form - Alaska Labor Relations Agency

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ALASKA LABOR RELATIONS AGENCY
Case No.
3301 EAGLE STREET, SUITE 208
P.O. BOX 107026
ANCHORAGE, ALASKA 99510-7026
Date Filed
Phone (907) 269-4895 Fax (907) 269-4898
PUBLIC EMPLOYMENT RELATIONS ACT EXEMPTION CLAIM [AS
23.40.225, AS 42.40.880; 8 AAC 97.310]
Instructions: Submit an original and four copies of this claim to the Alaska Labor Relations
Agency office at the above address. If more space is required, attach additional sheets.
The purpose of this claim is to claim nonassociation with a labor organization on the basis of bona fide religious convictions
based on tenets or teachings of a church or religious body of which an employee is a member under AS 23.40.225.
1. Name of Employee Claimant
2. Telephone No.
3. Position Name and Number
4. Address
5. Name of Recognized Bargaining Agent
Affiliation
a. Name of Contact Person for Recognized Bargaining Agent
o
o
6. Copy of claim mailed to recognized bargaining agent?
Yes
No
I, _______________________________, say on oath or affirm that my sincerely held religious beliefs
prohibit the payment of dues, initiation fees, or assessments to a labor organization or employee asociation.
Signature of Employee Claimant
SUBSCRIBED AND SWORN TO OR AFFIRMED before me at
, Alaska, this
day of
,
.
Notary Public in and for Alaska
My Commission Expires:
RSVD: 9/15/97
F:\DATA\CO\ALR\P&P\RELIGIOUS/RELIG01.DOC

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