Applicant’s Name: _____________________ Social Security No: __________________

Address: ___________________________ Telephone No: ( ) __________________

City, State, Zip Code: ____________________________________________________________

Date of Birth: ___________________________ Age: ______________________________

School/University: _________________ Enrolled: _______ Date accepted: ___________

Address: __________________________________________________________________

City, State, Zip Code: ____________________________________________________________

Applicant is the son, ____, daughter ______, other legal dependent ______ of a Millwright Local No. 1755 member in good standing.

__________________________ _____________________________

Date Applicant’s signature

Member’s Name: _____________________ Social Security No: __________________

Address: ___________________________ Telephone No: ( ) __________________

City, State, Zip Code: ____________________________________________________________

How long a member? ________________

I certify that I am a member in good standing of Millwright Local Union #1755 and have been for at least one (1) year prior to the date of this application. I further certify that the above-noted applicant is my son, daughter or other legal dependent (step child) and has been accepted or is enrolled in a program at an institution of higher learning as noted above.

__________________________ _____________________________

Date Member’s signature

NOTE: This application must be received by Local Union #1755 on or before May 1, 2010. A Copy of an acceptance letter from the school must be attached.