Application for Membership

Membership in 1199 is without regard to race, color, sex, sexual orientation, age, disability, religion, national origin, political belief or affiliation.

First Name*

Last Name*

Birth Date*

Middle Name

Street Address*

City*

State*

ZIP*

Home Telephone Number*

E-Mail*

Ethnic Origin

Other

White (Caucasian)

Black

Latino/Hispanic

Asian/Asian American/Pacific Islander

Native American/Alaskan Native

Ethnic Origin (if OTHER above)

Sex

Male

Female

Are you a person with a disability?

Yes

No

Are you a citizen of the U.S.?

Yes

No

If NO, which country are you a citizen of?

If YES, are you registered to vote?

Yes

No

Have you joined the 1199 Political Action Fund?

Yes

No

(see application on following page)

Have you ever been a member of 1199 before?

Yes

No

If YES, where?

Check-Off Authorization

Yes, I agree to all statements under "Union Dues Check Off Authorization" on this page.