LOCAL 26 REGISTRATION APPLICATION

REGISTRATION APPLICATION LOCAL 26

Residential Wireman
Date:*

MonthDayYear
Date
Name*

First NameLast Name
Time

:HourMinutesAM/PM Option
Social Security Number*
Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email:*
example@example.com
Membership Card#:
Local Union #:*
Zone Designation:*

METROPOLITANSHENANDOAHROANOKEALL ZONES
*RACE:

CAUCASIAN:AFRICAN AMERICANHISPANICAMERICAN INDIANASIANPACIFIC ISLANDEROTHER
* This identification is for statistical purposes only, will be kept confidential, and will not be used for any purpose that would violate Title VII of the Civil Rights Act of 1964, as amended.
Upload a photo of your driver's license, dues receipt, termination slip (if you have one)

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I do hereby acknowledge that I will receive a copy of the Referral Rules, dated June 24, 2021, once I have submitted this registration form. I understand that it is my responsibility to review the Referral Rules and that I am required to abide by the rules and procedures set forth in those Rules.
Signature:*

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REGISTRATION APPLICATION LOCAL 26