Please print or fill out below for a Teamsters Local 525 WITHDRAWAL CARD

GET A WITHDRAWAL CARD

WHEN YOU ARE OFF WORK OR LEAVE YOUR

            Be sure to request a Withdrawal Card when leaving your job, even though your leave may be temporary.  The Withdrawal Card will benefit you if you are off for one full calendar month or longer.  The Withdrawal Card tells us that you are off work for one reason or another and tells us to stop charging you the monthly union dues/fees until you physically return to bargaining unit employment.  There is no charge for a Withdrawal Card, but a written request must be made and all dues and fees must be paid before the Withdrawal Card is issued.  The Withdrawal Card does not change any rights or benefits you may or may not have under seniority, health & welfare or pension, but be advised that the Life Insurance Policy that the Local carries on your behalf is only in force for active paid up members.

            Stop by the office, or complete the form below and return it to our office.  It is your responsibility to obtain a Withdrawal Card.  Withdrawal status of more than a 30 day period will be considered a break in service for eligibility to office.  Please take care of this as soon as possible when you are off so that you will not be obligated to pay extra dues/fees.  Failure to obtain a Withdrawal Card may cause you to pay back dues/fees and/or a reinitiation fee upon your return.

WITHDRAWAL CARD REQUEST

NAME ____________________________________ LAST 4 #’S OF SSN_________________

ADDRESS___________________________________________________________________

PHONE NUMBER_____________________________________________________________

EMPLOYER__________________________________________________________________

LAST DAY OF WORK__________________________________________________________

REASON FOR LEAVING________________________________________________________

            (quit, laid off, leave of absence, medical leave, family leave, injury, terminated, non-                     union position, etc.)

SIGNATURE:___________________________________________DATE:_________________

Be sure to complete in full and return to:

TEAMSTERS LOCAL UNION NO. 525

Affiliated with the I.B.of T.

830 E. Broadway

Alton, Illinois 62002

Phone: 618-462-9706

Fax: 618-462-9720

To obtain information concerning continuation of the $1000.00 life insurance, contact:

Fort Dearborn Life Insurance Company

1020 31^st Street

Downers Grove, IL 60515-5591

1-800-348-4512

Policy Number: F00829          Account: 0001