First Name:_________________________ Last Name:__________________________________

Address 1:_______________________________________________________________________

Address 2:_______________________________________________________________________

City: ______________________________________ State: ________Zip:_____________

Phone: ( ______ ) _______ - _________ FAX: ( ______ ) _______ - _________

E-mail___________________________________________________________

Employer:________________________________________________________

Work Address 1: _________________________________________________________________

Work Address 2: _________________________________________________________________

City: _____________________________ State: _______ ZIP:______________

Product Manufactured: ___________________________________________________________

Number of Employees: __________ Number of Shifts: __________

To send this form by postal mail or to contact IAM Local 2053  by mail please write to:
 

IAM Local 2053
W3032 Hwy 33
Iron Ridge , WI  53035

To contact Local 2053 call
920-387-2053

or call Greg Jacobson at:

920-266-6092