See instructions on the back of this form. Attach additional sheets if needed, numbered according to the item to which they pertain. By signing the petition 

form, a labor organization/petitioner certifies it has submitted to the agency or activity and to the Department of Labor a roster of its officers and 

representatives, a copy of its constitution and by-laws, and a statement of its objectives.

UNITED STATES OF AMERICA 

FEDERAL LABOR RELATIONS AUTHORITY

PETITION

FOR FLRA USE ONLY

9. I declare that I have read this petition and that the statements in it are true to the best of my knowledge and belief. I understand that making

willfully false statements can be punished by fine and imprisonment, 18 U.S.C. 1001. This petition was served on all parties known to be affected by

issues raised in this petition.

___________________________

Date

_________________________________

Type or Print Your Name and Title

________________________________ 

Your Signature

Case No.

Date Filed

1. Clear and concise statement of the purpose of the petition and the issues raised by the petition.

2. Description of the unit(s):

Included:

Excluded:

3. Approximate number of employees in the

unit(s) affected by issues raised in the

petition.

4. If seeking an election, the petition is

supported by:

___ a showing of interest of not less than 30%

5. PETITIONER (full name of person, labor organization, or agency)

Petitoner Contact (Name and Title) Telephone No.

Address (Street, Number, City, State, & ZIP Code) 

6. AGENCY: Name of Agency affected by the petition (add attachment if more than one agency). Skip this section if same as Petitioner.

Date(s) of Recognition/Certification (ex. 01/30/2000) of any unit(s) 

affected by issues raised in the petition.

Expiration of Current Agreement(s) (ex. 01/30/2000) covering any 

unit(s) affected by issues raised in the petition.

7 .

FLRA Form 21(Rev. 5/17)

Currently:

Proposed:

Cell No. Fax No. Email Address

Petitoner Contact Address (if different than above) 

Address (Street, Number, City, State, & ZIP Code)

Agency Contact (Name and Title) Telephone No.

Cell No. Fax No. Email Address

Agency Contact Address (if different than above) 

LABOR ORGANIZATION: Name of Labor Organization affected by the petition (include local no. and affiliation, add attachment if more 

than one labor organization). Skip this section if same as Petitioner.

Address (Stree t, Number, City, State, & ZIP Code)

Labor Organization Contact (Name and Title)

Cell No.

Labor Organization Contact Address (if different than above) 

Telephone No.

Fax No. Email Address

8a. 8b.
OVERVIEW: Use this form to file a petition pursuant to Sections 7111, 7112 and 7115 of the Federal Service LaborManagement Relations Statute. You are encouraged to file a petition electronically using the eFiling system on the Federal Labor

Relations Authority’s (FLRA) website, www.flra.gov. Please only submit your petition once using one filing method (eFile, fax,

or mail). You must file your petition with the appropriate FLRA Regional Office. Visit www.flra.gov for the locations and 

contact information for the Regional Office nearest to you.

Submit your petition along with a statement of any relevant facts not contained in the petition and a copy of all relevant

correspondence relating to matters raised by the petition. If additional space is needed in the form, you may attach additional 

sheets numbered according to the item to which they pertain. You must file with any petition seeking an election or

determination for dues allotment a showing of interest and alphabetical list of names constituting the showing. Do not

provide a copy of the showing of interest and alphabetical list of names to any other party. You must serve a copy of the 

petition and accompanying materials (except the showing of interest and list of names) on all affected parties. After your initial 

filing, do not submit additional documents until you have a case number to reference. Refer to the Rules and Regulations of the 

Federal Labor Relations Authority (FLRA), Part 2422 of 5 C.F.R., for additional information on how to file a petition. 

PURPOSE OF THE PETITION AND STANDING TO FILE:

(A) Only a labor organization may file a petition to request: (1) an election to determine if employees in an appropriate unit wish 

to be represented for the purpose of collective bargaining by an exclusive representative, and/or (2) a determination of eligibility 

for dues allotment in an appropriate unit without an exclusive representative.

(B) Only an individual may file a petition to request an election to determine if employees in a unit no longer wish to be 

represented for the purpose of collective bargaining by an exclusive representative. You must submit with the petition a showing 

of interest or evidence of membership, as appropriate.

(C) An agency or a labor organization, or an agency and a labor organization jointly, may file a petition:

(1) to clarify and/or amend: 

(i) a recognition or certification then in effect (for example, to change the name or affiliation of the recognized or 

certified exclusive representative or the name of the agency; or to resolve questions related to the eligibility of employees

for inclusion in the unit); and/or 

(ii) any other matter relating to representation (for example, to resolve representation questions related to a reorganization 

or realignment of agency operations or issues related to the majority status of the currently recognized or certified labor 

organization); or

(2) to consolidate two or more units, with or without an election, in an agency and for which a labor organization is the 

exclusive representative.

LINE BY LINE INSTRUCTIONS:

1. Provide a clear and concise statement of the purpose of the petition, the issues raised, and the results the petitioner seeks.

2. Describe the unit(s) affected by issues raised in the petition. If the petitioner is seeking an election to determine the exclusive

representative of an appropriate unit of employees and/or a determination for dues allotment, the description should include the 

geographic location and classifications of the employees sought to be included in, or sought to be excluded from, the unit. If the 

petitioner is seeking an election to determine if employees no longer wish to be represented for purposes of collective bargaining 

by an exclusive representative or to clarify, amend or consolidate existing units, the petitioner should provide a description of the 

existing certification(s) or recognition(s). If more than one unit is affected, attach additional sheets.

3. State the approximate number of employees in the existing unit or the unit claimed to be appropriate; in a clarification or

amendment, state the approximate number of employees in the units affected by issues raised in the petition.

4. State whether a petition seeking an election is accompanied by a showing of interest of 30% of the employees in the unit

claimed to be appropriate. 

5. Provide the name, mailing address and other requested information for the petitioner and the contact person. If a labor 

organization petitioner is affiliated with a national organization, provide the local designation and the national affiliation. If an 

activity or agency is affiliated with an executive department, provide the name of the department. 

6. Provide the name, mailing address, and other irequested nformation for each activity or agency, other than the petitioner, 

affected by issues raised in the petition. If an activity or agency is affiliated with an executive department, provide the name of the 

department. 

7. Provide the name, mailing address, and other requested information for each labor organization, other than the petitioner, 

affected by issues raised in the petition. If a labor organization is affiliated with a national organization, provide the local designation 

and the national affiliation. 

8. If the labor organization(s) named in #7 is an exclusive representative of any of the employees affected by issues raised in the

petition, provide the date(s) of the recognition or certification and the date(s) any collective bargaining agreement covering the

unit(s) will expire, or the most recent agreement did expire, if known.

9. Type or print the name and title of the person filing the petition. The person filing the petition must also sign and date the petition.