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Membership Cancellation Form

First Name:

Last Name:

Email Address:

Phone Number:

Address:

Member ID:

Classification:

I understand that this request to let my membership drop will result in the following:

 I recognize that by no longer paying dues and submitting this request, I will forfeit all prior IBEW pension credits and death benefits

I have consulted with an IBEW 659 employee and understand the pros and cons for moving forward with this request.

 I will not be responsible for accrued dues and past dues will not be reported to a credit agency nor will it have a negative impact in the future.

Signature:

Use your mouse, finger, or touch device to write your signature.

Comments:


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IBEW Local 659
4480 Rogue Valley Hwy, Suite 3
Central Point, Oregon 97502
  541-664-0800

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