Withdrawal Request.

____Upon submitting this Withdrawal Card, I do hereby certify under penalty of perjury that I have no pending claims under the Grievance Procedure of my Collective Bargaining Agreement and that I further have no claims to be asserted under the Grievance Procedure of my Collective Bargaining Agreement.

--Full Name (First & Last): ________--Last 4 Digits Of Your SSN:

--Employer: ___________--Job Classification:

--Email Address:

--Day Time Phone Number: (xxx-xxx-xxxx) _______--Evening Phone Number: (xxx-xxx-xxxx):

--Street Address: --City: --State: California _--Zip:

--Enter The Last Day You Worked: (xx/xx/xx)

--Choose Your Reason For Withdrawal: Choose One... Disability Terminated Resigned Changed to Non-Union Position Other If Other Please State Reason Here:

--To Be ELIGIBLE for a withdrawal card, your initiation fees must be paid and your monthly dues must be current.

Are your dues current and initiation/trasnfer fees paid? Select Yes: Yes No

--It Is YOUR responsibility to notify the Union immediately upon your return to a Teamsters capacity.Click the check box to indicate you understand your responsibility:

Yes I understand my responsibility to notify the Union.

To Submit this form online click Here:

To Download This Form and Mail It In Click Here: {Download PDF}

-Print form, make sure all fields are filled in, mail to address at the bottom of the form.