Please indicate who you would like to list as your beneficiary of Local 517 Death Benefit:

Emergency Contact Information

EEOC Classifications - The following questions are asked solely for the purpose of meeting federal record keeping required by affirmative action. This hiring hall is administered without reguard to race, color, religion, sex, martial status, sexual orientation, national origin, disablility, age or veteran status, and in accordance with Federal, State and local laws.

Employment History - Please list pipeline, construction, environmental and industrial employers with job locations and employement dates for the last 2 years with MOST RECENT FIRST.

Skills and Certifications - Please select all Skills you are cabable of and or have performed in the past and for wich you would like to be coinsidered for work. Select all CERTIFICATIONS you have licenses for and when they expire.

I certify that all of the information submitted by me on this form is true and accurate to the best of my knowledge. I also understand that, it is my responsibility to update any current or relevant information on this form. I also understand that I must notify the local via telephone, fax, or writing on the last 5 days of each quarter that I wish to maintain my status on the referral list or I will be removed from the list without notice.