Please provide the following information via email or fax this form to (404) 688-6236.
NAME:_______________________________________________________________
HOME ADDRESS:______________________________________________________
WORK LOCATION:_____________________________________________________
HOME PHONE:________________________________________________________
WORK PHONE:________________________________________________________
PERSONAL CELL:_______________________________________________________
WORK CELL:__________________________________________________________
HOME E-MAIL ADDRESS:________________________________________________
WORK E-MAIL:________________________________________________________
PERSONAL I-PAGE ADDRESS:____________________________________________
OTHER CONTACT NUMBER(S):___________________________________________
PREFERRED PICKET DAYS:_______________________________________________
PREFERRED PICKET TIME:_______________________________________________
Please fill out and send before ASAP
If you have any questions, please contact CWA Local 3204Mobilizing Chair Kevin Kimber at 404.614.3227
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