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Merit System Protection Board Appeal Form

* indicates required form fields. Missing entries will be listed at the bottom of the page.






General Information:
First Name:* Middle Name:
Last Name:*
Home Phone:* Work Phone:
Email:*
Mailing Address
Street Address 1:* City:*
Street Address 2: State:
Zip Code:*















Are you a current county employee?*
Title/Position: Grade:
 
Name of the Department that took the action or made the decision you are appealing:*











   Type of personnel action or decision you are appealing:*
    (Please check the one that applies.) 
  

  

  
 
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.)*







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.