LOCAL 2078 LONGSHOREMAN LONGSHOREWOMAN

Employee Info Update Form

EMPLOYEE INFORMATION UPDATE

International Longshoremen’s Association – Local 2078

4921 Broadway Ave, Tampa, FL | (813) 807-7006

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1. Employee Information

First Name M.I. Last Name

Member / Badge # Effective Date of Change

What is changing? (check all that apply)

Previous Name (if name changed)

2. Contact Information

Street Address Apt / Unit

City State ZIP

Mobile Phone Other Phone Email

OK to text me work and union notices (reply STOP anytime to opt out)

3. Emergency Contacts

Primary Emergency Contact

Full Name Relationship

Phone Other Phone

Secondary Emergency Contact

Full Name Relationship

Phone Other Phone

4. Other Changes / Notes

Anything else the office should update

I certify the information above is correct. I understand I must notify the union office of any future changes.

Employee Signature

Date

FOR UNION OFFICE USE ONLY

Received by:Date received:

Entered in records on:Sent to: ☐ Gulf ☐ Logistec ☐ Other