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GRIEVANCE AND APPEAL Civil Service Commission Ogden City, Weber County State of Utah GRIEVANCE AND APPEAL OF: ) ) GRIEVANCE AND APPEAL ) ) DATED: ) EMPLOYEE INFORMATION Name: Position: Range/Step: Immediate Supervisor: Department Director: GROUNDS FOR APPEAL Date of Incident/Action: Statement of Facts: (attach additional pages if necessary) City Policy Violated: Witnesses: REMEDY REQUESTED Describe desired remedy: ---PAGE BREAK--- VERIFICATION The undersigned hereby verifies the accuracy of the information contained herein and requests an Administrative Hearing to resolve this Grievance/Appeal. Date Employee Signature Address (where all notices pursuant to this grievance will be sent) Daytime telephone number This form and information contained herein is a public document. The completed form must be filed within 5 calendar days from the date of final action by the Department Director, and must be filed in the Office of the City Recorder, 2549 Washington Blvd., Suite 210, Ogden, Utah, Monday through Friday, between the hours of 8:00 a.m. and 5:00 p.m. OFFICE USE ONLY – Do Not Write Below This Line Received: Date Time By Copies to: Legal Personnel Department Director Civil Service Commissioners Date By