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First Name:_________________________ Last Name:__________________________________

Address 1:_______________________________________________________________________

Address 2:_______________________________________________________________________

City: ______________________________________ State:________Zip:_____________

Phone: ( ______ ) _______ - _________ FAX: ( ______ ) _______ - _________

E-mail___________________________________________________________

Employer:________________________________________________________

Work Address 1: _________________________________________________________________

Work Address 2: _________________________________________________________________

City: _____________________________ State: _______ ZIP:______________

Product Manufactured: ___________________________________________________________

Number of Employees: __________ Number of Shifts: __________

To send this form by postal mail or to contact IAM District 10 by mail please write to:
 

Main Office
IAM District 6
222 Prospect Place S.W.
Cedar Rapids, IA 52404

FAX
319-364-1067

To contact District 6 call
319-364-2459