SOCIAL SECURITY NO.
FIRST NAME
MI
LAST NAME
Address
Street Address
Apt/Unit
City
State / Province
Postal / Zip Code
CELL PHONE NUMBER*
HOME PHONE NUMBER
EMAIL ADDRESS
example@example.com
DATE OF BIRTH (MM/DD/YY)
/
Month
/
Day
Year
Date
GENDER
EMPLOYER NAME
Store #
LOCATION
START DATE (MM/DD/YY)
/
Month
/
Day
Year
Date
DEPARTMENT
FULL TIME or PART TIME
CURRENT HOURLY WAGE
EMPLOYEE #
LANGUAGE
WERE YOU PREVIOUSLY A MEMBER OF UNITED FOOD & COMMERCIAL
PREVIOUS AFFILIATED LOCAL NO.
APPLICANT'S SIGNATURE
Date signed
-
Month
-
Day
Year
Date
JOB CLASS
STORE#
LOCAL UNION EXECUTIVE OFFICER'S SIGNATURE
AFFILIATION DATE (MM/YY)
/
Month
/
Day
Year
Date
WAGE RATE
B.A.
Print Name
Signature
Date
/
Month
/
Day
Year
Date
Last 4 digits of Social Security Number
Amount other than suggested guideline:
Date
/
Month
/
Day
Year
Date
Signature
Name
First Name
Last Name
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