MEMBERS

Find Your Union Representative

FORMS

Safety Concern

First and Last Name

First Name

Last Name

Cell Phone

(###)

###

####

Company

Facility

Description of Safety Concern

ABC

I AUTHORIZE the above amount to be remitted to UFCW Local 7R ABC, at such time and in such manner as may be agreed upon by my employer named above and UFCW Local 7R. Also, I UNDERSTAND that this authorization is voluntarily made and that the amount suggested as a contribution is a guideline and that I may contribute more or less than this amount by any lawful means, other than checkoff, or may refuse to contribute at all. I UNDERSTAND that the making of payments to the UFCW Local 7R ABC is not a condition of membership in the Union or a condition of employment and that I have the right to refuse to sign this authorization and not contribute to the UFCW Local 7R ABC without reprisal. In addition, I UNDERSTAND that my contribution will be used for political purposes, including the support of candidates for federal, state and local elections, including the support of candidates for public office. I UNDERSTAND that I expressly reserve the right to revoke this authorization at any time in writing. Lastly, I UNDERSTAND that contributions or gifts to the UFCW Local 7R Active Ballot Club are not deductible as charitable contributions for federal tax purposes.

First and Last Name

First Name

Last Name

Cell Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Last 4 SSN

Electronic Signature

I authorize my company to deduct the following from my paycheck:

$0.25 weekly

$0.50 weekly

$1.00 weekly

$1.25 weekly

1.50 weekly

1.75 weekly

2.00 weekly

Other

Other amount

Update Your Contact Info

Please not that this update is for current UFCW Local 7 members. This DOES NOT update your address with Zenith Administrators in regard to your Pension or Health Insurance.

First and Last Name

First Name

Last Name

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Change of Address

Please not that this update is for current UFCW Local 7 members. This DOES NOT update your address with Zenith Administrators in regard to your Pension or Health Insurance.

First and Last Name

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Bible Request

First and Last Name

Person Filling Out Request

First Name

Last Name

Cell Phone

(###)

###

####

Name of Member

Bible Recipient

Facility

Bible Recipient

Relation

Bible Recipient

Type of Bible

Report a Pay Issue

Name

First Name

Last Name

Last 4 SSN

Store / Facility #

Phone

(###)

###

####

Pay Period Incorrectly Paid

Additional Comments

Baby Onsie Request

Congratulations! Your Union would like to welcome your baby with a Local 7 onsie in honor of being Union Made!

First and Last Name

First Name

Last Name

Cell Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Retail Wage Theft Survey

Healthcare Wage Theft Survey

Packing Wage Theft Survey

INSURANCE INFORMATION

Teladoc

www.teladoc.com
or 1-800-Teladoc

Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits. It’s an affordable option for quality medical care.

Dispatch Health

www.dispatchhealth.com
or 720-647-5329

After requesting care via app, online or a quick phone call, DispatchHealth’s board-certified medical teams will arrive at your house, equipped with all the tools necessary to treat you. We treat a wide range of injuries and illnesses, from common to complex.