Representative Information Form

Please complete this form by entering the information in the boxes provided, some are required (*). This form is ONLY for use by the National Office and the local.

IMPORTANT NOTE FOR LOCAL PRESIDENTS: In order to facilitate communication with our union, we are asking Local Presidents to allow us to publish their name, phone number and email address on the USJE website.

Term of Office

From *

To *

Contact Information

Full Name *

Union Position Held *

Local Number *

Region *

PSAC ID *

Telephone (Home)

Telephone (Work)

Cellphone

Personal/Union Email *

Home Address

City

Province

Postal Code

Contact information changed because:

Elected to the position ofPresidentVice-President1st Vice-President2nd Vice-PresidentSecretaryTreasurerSecretary TreasurerChief Shop StewardShop StewardGrievance CoordinatorHealth and Safety Representative (OSH)

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Replacing

Changed position toPresidentVice-President1st Vice-President2nd Vice-PresidentSecretaryTreasurerSecretary TreasurerChief Shop StewardShop StewardGrievance CoordinatorHealth and Safety Representative (OSH)

Select all that apply (hold ctrl or cmd when selecting)

Changed Name

Changed Phone

Changed Email

Changed Address

Resignation Date

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