UFCW LOCAL 555 WITHDRAWAL REQUEST FORM

Purpose: If you are going to be gone for a longer than one month, you do not need to pay dues. Therefore, below is a withdrawal card application for your convenience. Please complete it and return it along with any dues you might still owe (please contact Membership Records to inquire about your balance.) Request a withdrawal card when you leave your job for any reason (sick leave, quit, suspension, laid-off, personal leave, etc.) so you are not billed.

Important: You must notify the Union Office when you return to work and you will need to complete the Union Application before your membership can be reactivated.

Social Security Number: _____ - ____ - _____

Last Day Worked: ____ / ____ / 20___ Number of Hours? _______

Full Name: ________________________________

^{(Last Name) , (First Name)}

Address: _________________________________________________

City: ______________ State: _____ Zip: ________

Phone #: (____) - _____ - ______

Last Employer (location): _________________________________________

Reason for Leaving: _____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I understand that, as a result of withdrawing from the UFCW Local 555, I will no longer be eligible for the Local Union death benefits. This form will only be processed and valid if signed.

Signature: ____________________ Date: _____________________

Complete and Return to: UFCW Local 555

PO BOX 23555

Tigard, OR 97281-23555