CENSUS FORM
Date of Birth
Social Security #
Gender (Circle One)
mm/dd/yyyy
M
F
/
/
Member’s Legal Name:
Marital Status (Circle one): S
M
D
W
___________________________________________________________________________________________________
Last
First
M.I.
Mailing Address: ____________________________________________________________________________________
___________________________________________________________________________________________________
City
State
Zip Code
Home Telephone # _______________________ Mbr Cell # ____________________ Spouse Cell #_________________
E-mail Address #1___________________________________
E-mail Address #2_______________________________
Mother’s Maiden Name: ______________________
Classification (Check one)
Local Union #
Union Book #
Welder/Journeyman
Helper
____________
____________
Beneficiary Death Benefit
(If this section is not completed, your beneficiary is your spouse, then your children, then your estate)
Primary:
________________________________
___________________________________________
___________________
Name / Relationship
Mailing Address
Social Security #
Secondary:
(Should the Primary be deceased.)
________________________________
___________________________________________
____________________
Name / Relationship
Mailing Address
Social Security #
LEGAL DEPENDENTS
The following members of your family are considered DEPENDENTS:
•
Your spouse
•
Your children under nineteen years of age
•
Your children from nineteen to twenty-six years of age who do not have insurance available through employment.*
•
*NOTE: These children are subject to annual open enrollment
Name of Spouse
(Enclose copy of Marriage Certificate)
Social Security #
Date of Birth
Date of Marriage
/
/
/
/
Dependent Children
(Enclose copy of Birth Certificate)
Social Security #
Date of Birth
Gender
Employer’s Name
Child’s Legal Name
(Circle One)
and Phone #
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
/
/
M
F
THIS FORM MUST BE FILLED OUT AND RETURNED TO THE FUND OFFICE
P.O. BOX 470950, TULSA, OKLAHOMA 74147-0950
TEL: 918-280-4800
I certify the information on this form is true and correct. I authorize the Administrative staff to make
changes to this card as requested by me in writing.
Signature of Member: _________________________________