IBEW Local No. 212 Trust Fund Questionnaire

[Pages:1]IBEW Local No. 212 Trust Fund Questionnaire

PLEASE PRINT THE FOLLOWING INFORMATION

Social Security Number Last Name

Address First Name

Date of Birth

Sex: Male Female

E-Mail Address Do you live in the city of Cincinnati

Yes N o

Home Local Union No.

City

State Zip Code

Middle Initial

( ) (Area) Telephone Number

CLASSIFICATION:

1-Joumeyman Inside Wiremen 5-Tele-data Journeyman

2-Apprentice Inside Wireman 6-Tele-data Cable Puller

3-Residential Wireman

7-Tele-data Apprentice

4-Residential Apprentice

8- Other

Spouse's Name

Spouse's Social Security Number

Spouse's Date of Birth

For Health & Welfare purposes, please list spouse's employer & insurance ca? rrier, if applicable.

Spouse's Employer

Pension Fund Name

H&W Fund

Name

S.U.B. Fund

Name

Address

Spouse's Insurance Co.

BENEFICIARY INFORMATION

Address

Address

Address

Address

Relationship Relationship Relationship

DEPENDENTS IN FAMILY INCLUDING SPOUSE - Same as those declared on Tax Return 1040 or 1040A

Name

1.

2.

Relationship

Social Security Number Date of Birth Sex

3. 4.

5. 6. 7.

In accordance with the laws of the United States and the State of Ohio, the information contained herein is for postemployment and apprenticeship reporting requirements only, and will not be used for pre-employment investigation.

Date

Member's Signature

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