IBEW 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.

* Date

* Employer

* Person Making Notification

* Phone Number

* Email (Referral Notice will be sent to)

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

* Last
Name

* First

Middle

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

* Date Of Birth

* Classification

* Start Date

* Wage Rate

Cancel and Exit