member of local no. 1626, not having been engaged in transportation service or in the service of the United Transportation Union for a full calendar month (excluding vacation), hereby make application to be relieved from the payment of dues and assessments, including JB/ISP assessments other than insurance premiums, beginning with the following month of    for the following reason:
Out of service date   

 Please answer yes or no 1. Reduction in force

2.Disabled by sickness or injury

3.Dismissed from service

4.Resigned from service (JBF/ISP automatically terminated)

5.Entered Military service

6.Retired* (JBF/ISP automatically terminated)

7. Other (specify)

*If totally disabled or having twenty (20) years continuous membership and retired from transportation service, The following is to be completed:
Have been a member continuously since

I agree to promptly report to the local Treasurer the date of my return to the active service of my employer and to pay full dues and assessments, including JB/ISP assessments, beginning with the first month thereafter.
Applicants name and ID#

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