Your Name *

Your Mailing Address To Receive Printed Materials from IWW (Optional but helpful)

Your Phone Number (Optional but helpful)

How do you prefer that we contact you? What is the best time to contact? *

What does your employer do? (eg: Car Wash, Grocery, etc.) *

How long have you been employed with this business? *

Do you work at a physical location or are you a remote worker? *

How many total employees does your employer have? (Estimate is fine) How many are at your work location? *

Have you had discussions with your fellow workers about organizing? How did those discussions go? How many are interested? *

What are your principle grievances? (eg: low pay, unsafe working conditions, mistreatment, sexual harrassment) *

What are your goals for organizing with the IWW? *

Are you currently represented by a labor union? If so, which union? *

Are you currently a member of the IWW? If no, would you like to talk to a delegate about joining? *

Would you be interested in attending an online meeting with our Organizing Committee to discuss your workplace situation? *

Please give us a fun code name that we can use to refer to your place of employment for security purposes (eg: "Pain at the Pizzeria" or "Big Box Blues")

Do you have any additional questions or comments for us?