APPLICATION FOR WITHDRAWAL CARD

APPLICATION FOR WITHDRAWAL CARD

Teamsters Local 769
Notice: BE SURE TO GET A WITHDRAWAL CARD
It is important to get a withdrawal card from the Local Union if you do not work and are not being paid by your Employer. This applies if you terminate your employment, go on unpaid sick leave, workers compensation, a leave of absence, are laid off, or for any reason you do not work and are not being paid by your Employer. Members must request a withdrawal card. Failure to request a withdrawal card will make you responsible for all back dues and possibly a re-initiation fee. Your request should be submitted before the end of the month in which you last worked. A withdrawal card allows a member to maintain his or her membership on an inactive basis. In other words, you will not owe union dues for any months you did not work after you obtain the withdrawal card. Additionally, this allows you to avoid paying a re-initiation fee when you return to employment.
Email*
example@example.com
Name*

First NameLast Name
I am applying for a withdrawal card for the following reason(s).
List reason(s) you are, or will be missing work.*
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Phone Number*
Please enter your HOME or MOBILE phone number.
Last 4 Digits Social Security*
Your Employer Name (company)*
Please be advised you must be paid through the month you are requesting your withdrawal card.
Last Day Worked*

MonthDayYear
Date
By signing and submitting this form, I certify that the information provided is true and correct to the best of my knowledge. I acknowledge that all information is subject to verification prior to the approval of any withdrawal. I further affirm that I am the Union member completing this form and that I agree to the provisions of Florida’s Electronic Signature Act, recognizing this electronic signature as legally binding.
Member Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: