- Attachment to Form NMB-3 -

The ___________________________________________ hereby enters the following

(Applicant Organization)

names, addresses, phone and fax numbers, and e-mail addresses for the individual(s)

designated as the representative(s) of_________________________________________

(Applicant Organization)

in connection with the Application for Representation Dispute:

• ____________________________ Phone No. ____________________

(Name & Title)

____________________________ FAX No. ______________________

(Address)

____________________________ ______________________________

(City, State, Zip Code) (e-mail address)

• ____________________________ Phone No. ____________________

(Name & Title)

• ____________________________ Phone No. ____________________

(Name & Title)