Request for Membership Application

First Name *

Last Name *

Employee ID Number *

Social Security Number (last 4) *

Phone Number *

Mailing Address *

Date of Birth *

Employer and Store Number *

Classification * Clerk (Drug Division) Combo Clerk Courtesy Clerk Food Clerk General Merchandise Clerk Meat Clerk Meat Cutter Meat Wrapper Pharmacist Pharmacy Clerk Pharmacy Tech Pharmacy Intern OTHER

Hire Date (Day you first started working) *