Health & Welfare and Dues Waiver

HW and Dues Waiver

Name(Required)

First Last

Phone #(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

UA Card #(Required)

Phone #(Required)

Name of School(Required)

Trade and Year of School(Required)

School Start Date(Required)

School End Date(Required)

Current Employer

List unemployed if you are currently out of work

Lay-off Date

Return Date (If Returning)