UFCW Local 1167 Information Change/Withdrawal Request form

UFCW Local 1167 Information Change/Withdrawal Request form
Name *

First Name Last Name
New Last Name

Check Only if New Last Name
Previous Last Name
Last 4 digits of Social Security number *
Email Address
example@example.com
Address *

Street Address

Apt/Unit

City State / Province

Postal / Zip Code
Is this a new Address

Yes No
Cell Phone Number

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Employer *
Store / Location Number
New Classification
New Classification / Promoted to
Effective Date

Month Day Year
Effective Date of Promotion
Request Withdrawal Card

Yes No
Reason for Withdrawal
Select if Requesting Withdrawal Card
Last Day Worked

Month Day Year
Date
Please verify that you are human *
Should be Empty: