Department List Request

Department List Request Form

One request per form -- submit multiple forms for multiple lists.
Your Name*

First NameLast Name
I am a:
My department is:
UW email (so we know who you are)
example@uw.edu
Non-UW email you'll use for accessing the list:*
example@example.com
Department that you're requesting list access for:
As part of organizing, you will have access to personal identifying information belonging to UAW members, and members of the broader UW community. This information may include:
- Personal cell phone numbers and email addresses
- Home addresses
- Notes about prior participation in union activities
- Membership, and VCAP status
This information should be used for UAW-related organizing purposes ONLY. You are agreeing to use these list for only officially endorsed union-positions (e.g. candidates, contract ratification, rallies, and endorsements). This information may not be used to solicit engagement for any non-UAW purpose (eg, an unrelated club or activity, a personal event, or any community event or rally that has not been previously authorized by the UAW 4121 Organizing Committee). This information may not be sold or used for commercial purposes of any kind.

Please treat others’ personal information with the consideration you would like your own information handled. This information should be considered private, and should not be shared with any individual or organization unless for the purpose of UAW-related organizing. Misusing information will result in access being revoked.
Yes, I have read the Data Usage Policy.
Should be Empty:

Department List Request Form