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No, 9704 P 3
Ron
Dale Flied
03CA-166874
INSTRUCTIONS:
12/31/2015
Flla on urlgliwl *I NLRB R banal Widow Far Ow i.giciri In table the d unfair labor pi,ok, oicurjid or.
. .
a. Name of Ernployar
c. Cell No:
- .
. d. Address (Street, di state, and ZIP code)
99 East State Street
e. Employer Representadve
Lana Wydra, PHR, VP of Human
Resources
f. Fax No
' 518479-5757
g. e-Mall
h. NUmber Of Others einployed.
. . ..
. .111priJX. 147
4a, Address (Street and nerribei, di); state, and ZIP code)
1.31 W. 33rd Street, Floor 3
New York, NY 10001
cfo Stephanie Beet
4c.Cell No,
46. FaK H- (212) 967-4279
4e. e-Mall
glephanlp,BpSL@NYSOA,org
...:.., . , ... .....
,,,...
6. Full naMe at nailenal Or intOrnationatiaber organization al which It is an affiliate or coneettient unit Ito be filled in Wheri'dierge le,pied by e Leber
ergenkation) New York State Nurses Aalociallon. .
.
.
6. DECLARATION
I declare (hal I have read III we c e end that the slatementstre true la the best of ray knowledge and bend
.
.
Bernard Mason, Associate Cotmsel
,
ignore otrepreet it or portal mak" dune) gortinnyet name and,* or dike, if erry1
..
.12/30/ 2015
(OW)
. .
Tel. No; .
(212) 7135-0157
Office, ,
If any Cell No.
FMK No
. (212) 967-4279
a-Mall
Bemard.Mason@NYSNA.org
WILLFUL FALSE STATEMENTS ON THIS CHARGE CAN BE PUNISHED BY 'FINE AND IMPRISONMENT (U.S. CoDE, TITLE18, isEcTION 1001)
PRIVACY ACT STATEMENT
Sddlcliation of the Information on Ihis form IS authorized by the National Labor Relations Ad (NLRA). 29 U.S.C. 151 et seq. The principal use of the Wormation It JO Gist's!
Me National Labor Relations Board (NLRB) In processing unfair labor practice arid related pnxeedings or litigation, The routine uses for Iheinformation are folly Set forth In
the Federal Register, 71 Fed. Reg. 74942-43 (Dec, 13. 2006). The NLRB will hid* whiff these uses upon request. Disclosure of this information to the NLRB IS
voluatery; however; failure to supply the Information will cause the NLRB to decline to Invoke Its practises.
Add131.W.