MICHIGAN UPPER PENINSULA IBEW PENSION

130 West Washington St.

Suite L 9

Marquette, Michigan 49855

906-226-2414

APPLICATION FOR PARTICIPATION IN PENSION PLAN

                      NAME                                                          SS#                                                     

                     NAME (SPOUSE)                                        SS#                                                     

                      YOUR ADDRESS                                                                                             

                      HOME PHONE NUMBER                                                        

                       YOUR BIRTH DATE                                                                 

                        SPOUSE BIRTH DATE                                                             

                        YOUR LOCAL UNION NUMBER                                           

                         PRIMARY BENEFICIARY                                                       

                         YOUR SIGNATURE                                                          DATE                                

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