LEA Referral Form – IBEW Local 292

Contractor Name
Request Made by:
First Last
Your name
Your Title
Phone
Employer Email

A copy of this form will be e-mailed to this address.
Employee
- New Union Member
- Existing Union Member
- Classification Change
Employer Acknowledgement*
I understand
When hiring a new member with a classification of Journeyperson Installer, Technician, Senior Technician, Journeyperson Technician OR changing a current members classification, supporting documentation shall be provided to warrant such hire or change. Once the documentation is reviewed, you will be notified of any questions or approval. Do not send the applicant in to pick up their referral until approval is received. Per Article 3 – Section 3.05. (b) Wages, Titles and Job Classifications of the Minnesota Limited Energy Agreement.
Insurance
- Local Union Health Benefit Plan
- Employer Provided Plan
Employee Name
First Middle Initial Last
Report Date
MM slash DD slash YYYY
Classification
Address
Street Address Address Line 2 City State ZIP Code
Phone
Employee Email

EMPLOYER EMAILS ARE PROHIBITED
Last 4 of SSN*
Date of Birth*
MM slash DD slash YYYY
Initiation Date: _____________________ Vacation Accrual Date: ______________ Health Care Eligibility:_______________
Supporting Documents
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 8 MB, Max. files: 10.
Notes
Untitled