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:______________

Product Manufactured: ___________________________________________________________

Number of Employees: __________ Number of Shifts: __________

To send this form by postal mail or to contact IAM District 5 by mail please use your computer print function, fill out this form and mail to:
 

Main Office
IAM District 5
617 South 15th Street, Suite B
Aberdeen, South Dakota 57401

FAX
(605) 225-9897

To contact District 5 call
(605) 226-1263