Associate Membership Request Form

Associate Membership Request Form

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, currently $5.73 per Sunday, effective April 1, 2026, $6.73 per Sunday. I understand that to be eligible for the death benefit, I must remain in good standing.
Member Name*

First NameLast Name
Todays Date

MonthDayYear
Date
Who did you speak to today?*
Last day of work was?

MonthDayYear
Date
Last four(4) digits of employee Social Security Number
Email
example@example.com
Should be Empty: