NOTE: You must be out of work one or more complete calendar months to be eligible.  Also, please note that when out on a withdrawal card, you are not longer eligible to purchase discount tickets to the movies or amusement parks and you are no longer eligible for the Death Benefit in the Membership Department.

Please call the Insurance Department and notify them of your leave/termination to find out when your Insurance coverage will end and how to stay eligible.

Please fill out all fields:

First Name:
Middle Initial:
Last Name:
Last 4 digits Social Security Number:
Address:	Unit :
City:	State:
Zip:
Home Phone:
Forwarding Address: (if changed)	Unit :
City:	State:
Zip:
Last Day Worked :	/ / MM/DD/YYYY
	Select reason for withdrawal Quit Terminated Pregnancy Transfer out of region Disabled or illness Promoted to management, non-union Leave of absence retired Military