CWA MEMBERS’ RELIEF FUNDSTRIKER CERTIFICATION FORM
Your Local
Bargaining Unit
Full Name
Address
Social Security Number:
Phone (Primary)
Phone (other)
E-Mail Address
Employer
Worksite
Stewards Name
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.
YES
Eligibility Verified Strikers Signature Sign using your finger or mouse pointer Todays Date
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