Authorization for Representation

I authorize Local Union No. 1 of the International Brotherhood of Electrical Workers to represent me as my bargaining representative in collective bargaining with my employer. This Authorization is nonexpiring, binding, and valid until such time as I submit a written revocation.

Full Name * (Print first, middle, and last name)

Home Address *

City *

State *

ZIP Code *

Mobile Phone *

Email Address *

(By including your mobile number you are authorizing the IBEW Local 1 to call you and get text alerts to you occasionally. We will never charge you for text message alerts but carrier message fees and data rates may apply. Reply STOP to any text from us to stop receiving messages or reply HELP for more information.)

Do You Understand and Agree to the Terms Above? *

Yes

Employer *

Location

Department

Manager

Job Title

Shift

Your Full Name *

Today's Date *

By clicking submit, you accept that your printed name, IP address and the date and time will be used as your digital signature for the purposes of this form.

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Form 141 Rev. 10/12