Tell us who you are!

* Name:


First	Last

* Email:

Address:

Country:

Home Phone:

CWA Local:

Employer:

Job:

Local Office You Hold:

Date of Birth:

Name of Company Retired From:

Date of Retirement:

Service at Retirement:

Age at Retirement:

Facility Worked At:

Title at Time of Retirement:

Were you a Local Officer?

Yes No

Are you a member of a CWA
Retired Members chapter?

Yes No

If yes, what chapter?

If no, would you like more information
sent to you regarding CWA Retired
Members chapters?

Yes No

Issue(s) you wish to
discuss or questions: