CWA Members' Relief Fund Striker Certification Form

CWA Members' Relief Fund Striker Certification Form
Questions marked by * are required.
1.	Local *
2.	First and Last Name *
3.	Street Address *
4.	City and State *
5.	Full Social Security Number (For W2 Purposes) *
6.	Phone Main *
7.	Other Phone
8.	Email: *
9.	Employer * AT&T Mobility
10.	Bargaining Unit: * AT&T Mobility
11.	Worksite *
12.	Date *
13.	Local Steward's Name
14.	Certification and Electronic Signature * I certify that I am eligible to receive strike benefits under the rules of the Members Relief Fund. I understand that if I am found ineligible under the rules, I will return any payments I am not entitled to.