IBEW 110

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Low Voltage Employment Notification

New Hire or Rehire for Local 110

When you hire or rehire a Local 110 Member, please complete and submit this form.
Instruct the employee that they are required to go to the Local 110 Referral Office to complete paperwork (M – F - 7:30 a.m. to 3:00 p.m.) and be prepared to pay dues and/or initiation fee at that time per the terms of the contract.
You will receive a Referral Notice via email once both of these items are completed.
Keep the Referral Notice on file; when they are no longer employed by your company, fill out the bottom portion and send to Local 110 Referral Office referral@ibew110.org.

For any questions on this form, please contact Teloa at tvolkman@ibew110.org or 651-776-4239 ext. 740.

* Date

Employer Information

* Employer

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* Person Making Notification

* Phone Number

* Email (Referral Notice will be sent to)

Union Health Plan	OR	Employer Health Plan
Union Annuity	OR	Employer Plan

Member Information

* Last
Name

* First

Middle

* Social Security #
XXX-XX- (please enter last four digits of SSN)

* Date Of Birth

* Classification

* Start Date

* Wage Rate

Each time a member is hired or rehired – they are required to report to Local 110 Referral Office to complete paperwork (M – F - 7:30 a.m. to 3:00 p.m.).

If after separation, you rehire the same person, please use the instructions at the top of this page and send in a new form.

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