I authorize the Carrier to deduct from my wages an amount necessary to pay my monthly union dues (not including fines and penalties) as reported to the Illinois Railway by the Brotherhood of Maintenance of Way Employes Division of The International Brotherhood of Teamsters. I authorize the Illinois Railway to remit that amount to the Brotherhood of Maintenance of Way Employes Division of The International Brotherhood of Teamsters. This authorization may be revoked in writing by me at any time after the expiration of one (1) year from the date I sign it.

I, the undersigned:

Apply for membership in the Brotherhood of Maintenance of Way Employes Division—IBT, and agree to abide by its Constitution and Bylaws;
Authorize this Union to be my exclusive bargaining agent.

First Name:
Middle Initial:
Last Name:
Phone Number
Cell Provider:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Email Address:
Social Security Number:	- -
Birth Date:
Preferred Greeting:	Brother Sister
Employee ID Number:
Service Entry Date:
Hire Location:
Occupation:
Are you a Veteran?
If yes, what branch?
Todays Date:
Signature	Signature: Use your mouse, finger, or touch device to write your signature.