Membership Application Form

APPLICATION AND NOTICE

FOR MEMBERSHIP IN LOCAL UNION NO. 222 AFFILIATED WITH THE INTERNATIONAL BROTHERHOOD OF TEAMSTERS
Name *

(FIRST NAME) (MIDDLE INITIAL) (LAST NAME)
Social Security No *
Phone *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Employer *
ABF Worksite *
ALSCO Worksite *
Bimbo Bakeries Worksite *
Dean Dairy's Worksite *
Geneva Rock Worksite *
Are you full time or part time?
UPS Worksite *
YRC Worksite *
Seniority Date *

Month Day Year
Date
Job Classification *
Rate of Pay *
Date Of Birth *

Month Day Year
Date
Gender *
Email *
example@example.com
Have you ever been a member of a Teamster Local Union? *
If yes, what Local Union No.
DATE OF APPLICATION *

Month Day Year
Date
Signature *

Clear
My Beneficiary Is *
Relationship *
Referred by Whom
CHECKOFF AUTHORIZATION AND AGREEMENT
Name *

First Name Last Name
Signature *

Clear
Social Security Number *
Date *

Month Day Year
Date
Address *

Address

Street Address Line 2

City State

Zip Code
Employer *
Should be Empty:

APPLICATION AND NOTICE