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Name *

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Phone Number *

Address *

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City

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Email *

Date of Birth (MM/DD/YEAR) *

In depth explanation of reason for application *

Local Union *

IBEW Local 5 IBEW Local 56 IBEW Local 712

Card Number *

RECENT WORK HISTORY

1. List name of all contractors you worked for in past 12 months? *

2. Name and location of jobs you have been on in past 12 months? *

3. Estimated number of months you have worked in past 12 months? *

ADDITIONAL QUESTIONS

4. What is your specific request for assistance? *

5. Has WPEE Member Assistance Program (LifeSolutions) been contacted regarding this situation? *

6. List all benefits applied for, exhausted and/or denied. *

7. What is your timeframe for assistance? *

AGREEMENT *

By clicking AGREE AND SUBMIT, I hereby:

Agree & Consent to meeting the Qualifying Criteria

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APPLY FOR AID

RECENT WORK HISTORY

ADDITIONAL QUESTIONS

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APPLY FOR AID

RECENT WORK HISTORY

ADDITIONAL QUESTIONS

HOME ABOUT DONATE

HOURS

TELEPHONE

EMAIL

WEB LINKS

WPANECA

LIFE SOLUTIONS

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