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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:______________ Type of Work / Industry: __________________________________________________________ Number of Employees: __________ Number of Shifts: __________ To send this form by postal mail or fax to Mechanics Local 701: Mechanics Local 701 To contact
Local 701 call FAX
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