Text Box: REGISTRATIONS ARE ON A FIRST COME-FIRST SERVE BASIS ONLY. NO REGISTRATIONS WILL BE ACCEPTED WITHOUT CHECK, CASH OR CREDIT CARD. YOUR REGISTRATION WILL BE CONFIRMED BY MAIL. MAKE CHECKS PAYABLE TO ST. PAUL ELECTRICAL JATC AND MAIL OR DELIVER TO: ST. PAUL ELECTRICAL JATC, 1330 CONWAY STREET, SUITE 150, ST. PAUL, MN 55106 OFFICE PHONE NUMBER: 651-772-8746 OR REGISTER ON-LINE AT: www.ibew110.org/jatc PLEASE PRINT: NAME_______________________________________________________________________ First Middle Last Name ADDRESS ________________________________________________________ CITY, STATE, ZIP ______________________________________________ LAST FOUR DIGITS OF SS#: __________ PHONE # _________________ JW STATE LICENSE #: ________________ EXP. DATE _______ MASTER LICENSE #: ________________ EXP. DATE _______ IBEW LOCAL #110 CARD NUMBER: ____________________ CURRENT CONTRACTOR: ________________ IBEW LOCAL #292 CARD NUMBER: ____________________ CURRENT CONTRACTOR: ________________ IBEW LOCAL #343 CARD NUMBER: ____________________ CURRENT CONTRACTOR: ________________ IBEW MEMBER—LOCAL UNION CARD NUMBER: ____________ LOCAL UNION #: __________________ PLEASE CHECK THE APPROPRIATE BOX BELOW IF IT APPLIES TO YOU: RETIREE__________ ON PARTICIPATING WITHDRAWAL__________ ON DISABILITY__________ ______ESTIMATOR/PROJECT MANAGER – CONTRACTOR________________ IF PAYING BY CREDIT CARD: AMOUNT ON CARD: _______________ NAME AS ON CARD: ___________________________________________ CARD TYPE:____________ CARD NUMBER:______________________________________________CARD EXP. #:_____________ 3 DIGIT NUMBER ON BACK OF CARD (IF LEGIBLE)___________________ IF REGISTERING FOR NEC UPGRADE CLASS PLEASE INDICATE 1st and 2ND CHOICE FOR CLASS DATE. IF YOU DO NOT RECEIVE CONFIRMATION BY MAIL TWO WEEKS PRIOR TO YOUR CLASS START DATE, PLEASE CALL THE JATC OFFICE. Text Box: FOR OFFICE USE ONLY: PAID BY CASH: AMOUNT______________ PAID BY CREDIT CARD: AMOUNT____________ PROCESSED ON:_______________ PAID BY CHECK: AMOUNT: ________________ CHECK NUMBER: ________________ CHECK DATE________________

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