Name:

Address:

City:

State abbreviation:     Zip code:

E-mail address:

Home phone:        work:        cell:  

International/Nat'l Union:    Local # 

NATIONAL MEMBERSHIP IN CLUW IS GOOD FOR ONE FULL YEAR FROM DATE OF ISSUANCE OF MEMBERSHIP CARD BY NATIONAL TREASURER. DUES, CONTRIBUTIONS OR GIFTS TO CLUW ARE NOT DEDUCTIBLE AS CHARITABLE
CONTRIBUTIONS FOR FEDERAL INCOME TAX PURPOSES.

I am a member of a bona fide collective bargaining organization (not required for student or associate members):     Yes     No

Date: