Last 4 digits of SS# *

Date Returned to Work *

Where do you work and what city? *

Info:

If you are returning to work from a leave other than paid time off, you must request a Withdrawal Card Deposit upon your first day back to work. Upon your return to work, you are responsible for the dues of the month in which you are returning. If you fail to notify the hall of your Return to Work, you will be responsible for the dues from the time that you were out plus fines.