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Get a Withdrawal Card
When You Are Off Work or Leave Your Job

Be sure to request a Withdrawal Card when leaving your job, even though your leave may be temporary. The Withdrawal card will benefit you if you are off for one full calendar month or longer. The Withdrawal Card tells us that you are off work for one reason or another and tells us to stop charging you the monthly union dues/fees until you physically return to bargaining unit employment. All dues and fees, currently owed, must be paid before the Withdrawal Card is issued.* The Withdrawal Card does not change any rights or benefits you may or may not have under seniority, health & welfare or pension.

Stop by the office, or complete the form below and submit it. It is your responsibility to obtain a Withdrawal Card. Please take care of it as soon as possible when you are off so that you will not be obligated to pay extra dues/fees. Failure to obtain a Withdrawal Card may cause you to pay back dues / fees and/or a reinitiation  fee upon your return.

Withdrawal Card Request

First Name:            

Last Name:       

Street Address:            
Apt. #:

City/Town:             State:            
Zip Code:       

Email Address:            

Last Day of Work:  month      dayyear

Reason for leaving (quit, laid off, leave of absence, medical or family leave, injury, terminated, etc)

all information above must be provided by you or the form will be cleared and not submitted

Note: I have since returned to work on : 
month      dayyear

For (Employer) :

*The office staff will contact you by phone and/or email if you have outstanding dues or fees that must be paid prior to issuance of the Withdrawal Card.*

Please do not click on Submit more than once - An error message may appear but your information has been submitted. Thank You

Local #676


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