Application for Withdrawal Card
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Employer
*
Are you still employed with this Employer?
*
Reason For Withdrawal
*
No longer employed by a Teamster represented company
Taking managerial position with employer
Temporary Withdrawal
Reason For Temporary Withdrawal
*
Leave of Absence
Illness or Injury
Layoff
Military Service
Other
Last date worked
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expected date to return to work
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you do not know when you will be returning to work, please explain:
When you return to work please give us a call so we can make your account active again.
Signature
*
Please verify that you are human
*
Submit
Should be Empty: