Provost & Academic V.P. Western Illinois University 1 University Circle 211 Sherman Hall Macomb, Illinois 61455 Phone: 309/298-1066 E-mail: PS-Brown@wiu.edu

WIU/UPI Agreement 2001-2005

Appendix D: Western Illinois University
UPI Local 4100
Step Two Grievance Form

Grievance No.:               Date

I hereby request that a Step Two Hearing Panel review the attached decision made in connection with the attached grievance because (please be specific):

I received the Step One decision on:
and filed this request for review with Western Illinois University Academic Vice President's office on
by (check one) [ ] certified registered mail, return receipt requested, [ ] personal delivery.

Signature of Grievant             (Month) (Day) (Year)

Signature of Union Representative    (Month) (Day) (Year)

Revised--Nov. 1996

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