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Justice for Labor Association

AUTHORIZATION FOR REPRESENTATION

I hereby authorize Justice For Labor Association to represent me
for the purpose of collective bargaining.

Member Contact Information

First Name: Last Name:

E-Mail Address:

Phone Number: ( ) -

Home Address:

City: State(2): Zip Code(5):

Mailing Address:

City: State(2): Zip Code(5):

Employer Information

Employer's Name:

Employer's Address:

City: State(2): Zip Code(5):

Employment Information

Hire Date: - - Job Classification:

Shift Day Swing Night

Work Status Full-Time: Part-Time:

Department:

Hourly Rate: $ Days Off:

Would you participate in an organizing committee? Yes No