Labor Community Services- Union Member Referral Form
This form should only be completed by an employee of a union for the purposes of referring their union's members for emergency assistance. Submission of this form verifies that the individual referred is a current member, in good standing.
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Name of Union and Local *
Union Staff Member Name *
Name of the person completing the referral form.
Title at Union *
Position within the union of the individual completing the form.
Phone Number *
How can we contact you?
Email Address *
Address of Union
Are you referring a union member for assistance? *
This form is only for union staff referring members of their union.
Is the union member in good standing with the union? *
Has the union member been referred to Labor Community Services in the past 365 days? *
Union members are eligible for assistance one time per calendar year.
Union Member Name *
Union Member Contact Number(s) *
Union Member Email Address
Union Member Zip Code
Is the union member a veteran? *
Union Member's Household Size
How many people live in the member's household?
Emergency Assistance Request *
What does the union member need assistance with?
Is the union member currently working? *
What is the total household income?
Does the member prefer to speak a language other than English? *
Brief description of the union member's emergency.
Why does this union member need assistance?
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