Appeal Request Form

Lets an employee formally request review of a workplace decision they consider unfair, attaching supporting evidence and signing the request.

Use this template

Name

Nombre

Apellido

Email

Phone Number

Date

Please choose the one(s) suitable for your case.

Unfair disciplinary action Discrimination Harassment Wrongful termination Denial of benefits Other

Please add a copy of the appealing notice.

Max 10 MB per file

I appeal that decision for the following reasons:

If I'm qualified, I'd like to keep my benefits during the appeal process:

Yes No

Please list any specific accommodations you'll need for the hearing. (e.g. handicapped access or translator):

Signature:

Sign here

Date Signed:

Additional Notes

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