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  • New Hire Information Form For Existing Members
    New Hire Enrollment Form. Don't Fill This Out If You Have Not Been Hired.

    First Name:   

     

    Middle Name: 

     

    Last Name: 

    Address:     

    City:                 

    State:               

    Zip:                   

    Cell Phone:      

    Home Phone:   

    Email:                

    Date of Birth:    
    Male:      
    Female:  

    Social Security Number:

    Company:

    First Day on the Payroll:

    Supervisor:

    Supervisor Phone Number:

    Highest Level of Education:

    8th Grade or Lower: 

    Some High School: 9-12 

    GED: 

    High School Graduate: 

    College Degree or Higher: 

    Do Not Wish to Answer: 

    Military Veteran 

    Yes 

    No 

    Do Not Wish to Answer 

    If a Veteran, are you a Vietnam Era Vet?

    Yes 

    No 

    Do Not Wish to Answer 
    Are you a Registered Apprentice in Another Trade? 

    Race: Select all that apply.

    African American or Black 

    Asian 

    American Indian or Alaska Native 

    White 

    Hispanic/ Latino  

    Native Hawaiian or Pacific Islander 

    Other 

    Ethnic Group:Must Choose one

    Hispanic Origin

    Not of Hispanic Origin

    Do Not Wish to Answer  

    __________________________________________________________________________________________

    Disability?

     Yes

    No

    Do Not Wish to Answer

    ___________________________________________________________________________________________

    Veteran  Status - Select all boxes that apply.

    Not a Veteran

     Armed Forces Service Medal Veteran -  A veteran who while serving on active duty in the U.S. military,

           ground, naval or air service, participated in a United States military operation for which an Armed Forces

            service medal was awarded pursuit to executive order 12955(61 Fed Reg 1209)

     Disabled Veteran   (i) A veteran of the U.S.military, ground, naval or air service who is entitled to compensation

           (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered

            by the Secretary of Veterans Affairs, or (ii) a person who was discharged or released from active duty 

            because of a service-connected disability. 

    Other Protected Veteran   A veteran who served on active duty in the U.S military, ground, naval or air service

           during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws 

           administered by the Department of Defense. 

    Three Year Recently Separated Veteran.    A veteran during the three year period beginning on the date of such 

          veteran discharge or release from active duty in the U.S. military, ground, naval or air service. 
    Enter the text shown in the image above.

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