Return To Membership Application
Please fill out the form in its entirety as soon as you start back to work to avoid back dues payment.
E-Mail Address:
Last Four SS#
*
Employer & Location
Date Withdrawal Card Was Issued by 492 (If you can't remember, put your best guess)
Date You Returned to Work
Do you want us to update your address information in our system?
Yes No
Sign below please