Electronic Authorization Form

Electronic Authorization Form

Member Information

Please select:
—Please choose an option—I am a coal minerI am a non-coal workerI am a construction worker

Your First Name

Your Last Name

Date of Birth

Last Four of Social Security Number

(This information is required in order to sign you up as a UMWA Member, it will not be shared with any entity outside of the union.)

Your Phone Number

Your Email

Your Mailing Address

Your Mailing City

Your Mailing State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your Mailing Zip Code

Your Employer

Date of Hire

Your Signature

Today's Date