I hereby apply for membership / reinstatement in the Teamsters, Brotherhood of Locomotive Engineers and Trainmen.

My name is ____________________________________________________________________________________

First Middle Last

Home Address __________________________________________________________________________________

Number and Street Address

______________________________________________________________________________________________

City State Zip Code

Social Security Number___________________________ Employee ID # _________________________________

Date of Birth ___________________________________ Telephone Number _______________________________

Month Day Year (include area code)

Employed by ______________________________________________________Railroad

I was formerly a member of BLE Division ____________________________(For Reinstatement Purposes)

I was hired _________________________ and currently working as _____________________________

Craft

I was promoted to Conductor _____________________, Locomotive Engineer _____________________

Date Date

I am making this application for membership / reinstatement because I believe the Teamsters, BLET is the best choice for a

secure and well-paid future in the rail industry, and I will cooperate with my fellow brother and sister members to achieve these

goals.

I wish to be included in the BLET Political Action Committee Fund in the amount of:

(If you choose to participate, check one) $5_______, $10______, $20 _______, Other $________.

Application to become effective __________________.

Date

Teamster, BLET Member Furnishing Application:        Ray Carver - President, BLE&T Division 56 

______________________________________________