APPENDIX V MONTGOMERY COUNTY GOVERNMENT MERIT SYSTEM PROTECTION BOARD APPEAL FORM

      *   indicates required form fields

•	General Information
•	First Name *
•	Middle Name
•	Last Name *
•	Home Phone *		### - ### - ####
•	Work Phone		### - ### - ####
•	Email. *
•	Mailing Address
•	Street Address 1 *
•	City *
•	Street Address 2
•	State
	Maryland
•	Zip Code *
•	Are you a current county employee? *
	Yes	No
•	Title/Position:
•	Grade
•	Name of the Department that took the action or made the decision you are appealing *
	Select

•	Type of personnel action or decision you are appealing*
•	(Please check the one that applies.) *
•	Disciplinary Action
•	Date you recieved the Department’s Statement of Charges * ____MM / ____DD / ______YYYY
•	Date you responded to the Statement of Charges * ____MM / ____DD / ______YYYY
•	Date you received the Department’s Notice of Action * ____MM / ____DD / ______YYYY
•	Effective date of the Department action or decision * ____MM / ____DD / ______YYYY
•	Denial Of Employment
•	Date you received the Department’s Notice of denial * ____MM / ____DD / ______YYYY
•	CAO Denial of grievance
•	Date you received the Chief Administrative Officer (CAO)’s decision * ____MM / ____DD / ______YYYY
•	Explain briefly why you think the Department was wrong in taking this action or making this decision *
•	What action would you like the Board to take in this case (i.e, what is the relief/remedy you are requesting)? *
•	Do you wish to designate an attorney to represent you in this proceeding before the Board? (You may designate a representative at any time. However, the processing of your appeal will not normally be delayed because of any difficulty you may have in obtaining a representative.) *
	Yes	No
•	Representative’s Information
•	Representative’s First Name *
•	Middle Name
•	Last Name *
•	Phone Number *		### - ### - ####
•	Fax
•	Email *
•	Mailing Address
•	Street Address 1 *
•	City *
•	Street Address 2
•	State
•	Zip Code *
•	Certification
	By clicking on this submit button you are certifying that all of the statements made in this form are true, complete and correct to the best of your knowledge and belief. Upon clicking the submit button, the MSPB will receive this appeal and a copy of this appeal will automatically be sent to the Office of the County Attorney, in accordance with Section 35-5(a) of the Montgomery County Personnel Regulations.
•	Submit