Attention Travelers!

Dues are your responsibility; we do not bill you.

Dues are due from the date of hire.

Working Dues Assessment: One and One-Half Percent (1 ½%) of total gross wages.

Organizing Dues Assessment: When assessed, will be one percent (1%) of total gross wages.

All Units employed under Construction Contracts (Inside Wire, Sound & Communications, Residential, Stockman and Light Fixture Maintenance) will pay Organizing Dues.

NAME:________________________________________________ DATE: _____________________

PERMANENT:________________________________________________________________________

                              ADDRESS                                     CITY                      STATE   ZIP CODE

TEMPORARY: _______________________________________________________________________

                              ADDRESS                                      CITY                      STATE   ZIP CODE

PERMANENT PHONE #_____________________________

TEMPORARY PHONE # ______________________

SOCIAL SECURITY # ___________________ DATE OF BIRTH ____/____/____ GENDER (M) ___ (F) ___

HOME LOCAL UNION ___________________________ CARD # ___________________________

RACE (FOR EEOC):        AMERICAN INDIAN        ASIAN      BLACK      CAUCASIAN         HISPANIC

JOB CLASSIFICATION: ______________________________________________________________

COMPANY DISPATCHED TO: ________________________

DATE TO WORK (IF DISPATCHED) ______________

SIGNATURE OF TRAVELER: _______________________________

DATE: _______________________________