LiUNA 189 Member Application

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Last Name

First Name

Middle Initial

Social Security Number

Address

Zip

City

State

County

Mobile Number

Home Phone

Permission to Text *

We will text you with job information, meeting reminders, and other important Local information

Yes

Drivers License Number

Registered to Vote

Yes

Email Address

Race

Gender

Birth Date

Current Employer

Employer Address

Present Salary

Employment Start Date

Job Description

What type of work do you currently do?

Report for work

When can you start work if accepted as a member?

Are you a convicted felon

Yes

Prev Employer Name

Prev Employer Address

Job Title

Prev Employer Telephone

Prev Employer Start Date

Prev Employment End Date

Hours per week

Last Salary

Supervisor