Associated Membership Request Form

I, First Name Last Name become an associate member. I will continue to be a member and will pay a lower monthly dues to keep the Local 1167 death benefit in effect. I understand that to be eligible for the death benefit, I must reamin in good standing.
I would like to become an associate member. I will continue to be a member and will pay a lower monthly dues to keep the Local 1167 death benefit in effect. I understand that to be eligible for the death benefit, I must remain in good standings.
Today's Date

YearMonthDay
Date
What is the name of who you spoke with today?
Your last day of work was?

MonthDayYear
Date
Members Name

First NameLast Name
Last 4 of SSN
Email
example@example.com
Please verify that you are human*
Should be Empty: