Membership Application
You must be a Resident
of North or South Carolina to Apply

Name:
Street:
City: State:

Zip:

email adr:

Home Phone:

Cell Phone:

Race (optional):

Gender:

 M F

Date of Birth:
Are you registered to vote?  Yes No

What Political District are you in?

Congressional:

Senate:

 House:

Occupation:

Present Employer & Job Site:

Pay Scale:

Benefits:

Former U.A.
Member?

 Yes No

Local No:

When:
State License

Plumbing:

Yes No

Journeyman
License #

Master
License #

H.V.A.C.

 Yes No

Class 1:

Class 2:
Certifications

Certification Type:

Date
Certified:

Expiration
Date:

Where Certified:
Previous Experience (yrs): Journeyman: Apprentice:
Employer for whom you worked at the trade:
For Office Use Only:
Credit for Previous
Experience:		 Years: Months:
Journeyman: Apprentice:
Authorized Agent: Date: