Pacific Northwest Regional Council of CarpentersMILLWRIGHT READY-TO-WORK LIST QUESTIONNAIRE

Millwright Central Dispatch: 1-800-953-6444 Fax: 253-945-8875

Send to: Dispatch, PNWRCC, 25120 Pacific Hwy S, Ste 200, Kent, WA 98032 PLEASE PRINT LEGIBLY!

Check 4 here. I am:[ ] Journeyman millwright[ ] Apprentice millwright Term[ ] Assembler (190)

Name UBCID# UBCLocal#

Address DateofBirth

City State Zip Phone#

Email Phone#

Ethnicity(Optional): []Asian []HispanicorLatino []White []BlackorAfricanAmerican[]NativeAmericanorAlaskaNative []Other

I (print name), assign to the Pacific Northwest Regional Council of Carpenters, from my earnings, a sum equal to the Union’s membership dues, assessments, and initiation fee (the Union will notify my Employer of the current amount). I authorize and direct my Employer to deduct such sum and remit the money to the Union monthly. This assignment is irrevocable for one (1) year from this date or until the termination of the Labor Agreement, whichever occurs first. This assignment shall be renewed automatically, for succes-sive 12 month periods, unless the Union and my employer receive my written notice of termination of this assignment not more than twenty (20) days and not less than ten (10) days prior to renewal of the assignment. This authorization is effective regardless of my status as a member, non-member, or “financial core” payer and applies regardless of any future resignation of membership on my part.

I hereby authorize the UNITED BROTHERHOOD OF CARPENTERS AND JOINERS OF AMERICA to act as my collective bargaining agent in dealing with my employer in regard to wages, hours, and other conditions of employment. All previous authorizations made by me are revoked.

Signature Date

3.2011/sek/opeiu8alfcio

I AM CERTIFIED IN THE FOLLOWING SKILLS. DOCUMENTATION REQUIRED. (Mark with a check 4 below.)

[ ] Burning (167) [ ] Nuclear Experience (160) [ ] Welder, Non-Certified (127)[ ] Conveyors (193) [ ] Precision Optics (225)[ ] Dryer Can Accessible (162) [ ] Refinery Experience (161) [ ] Machinist (159) [ ] Regular Dial Alignment (165)[ ] Roto (Laser) Alignment (163) [ ] Other (List here or on back.)

TURBINE EXPERIENCE:[ ] Steam (169) [ ] Gas (170) [ ] Hydro (171) [ ] Wind (306)

I AM QUALIFIED IN THE FOLLOWING SKILLS: (Mark with a check 4 below.)

Check 4 the areas where you are willing to work. Re-fer to the enclosed area map.[ ] Area 1 [ ] Area 4[ ] Area 2 [ ] Area 5[ ] Area 3

Millwright Certifications:[ ] UBC Qualified (175)#[ ] OR/WA Qualified#[ ] Other Qualified#Where issued:

(Please include area code.)

(Please include area code.)

[ ] CFATS Security Clearance (203)

[ ] Cleanroom Class (176)

[ ] Confined Space Cert (152)

[ ] Crane/Boom Truck Cert (144)

[ ] C-Stop Cert (142)

[ ] 1st Aid / CPR Cert (121)

[ ] Flow Serve Cert (211)

[ ] Foreman - A Cert (139)

[ ] Forklift Industrial (122)

[ ] Forklift Rough Terrain (103)

[ ] GE Turbine (179)

[ ] HAZMAT Cert (149)

[ ] Human Performance Cert (196)

[ ] OSHA 10 (208)

[ ] OSHA 30 (212)

[ ] Overhead Crane Op Cert (191)

[ ] Rigging Cert (145)

[ ] Scaffold Erector (110)

[ ] Scaffold User (124)

[ ] Steward Cert (112)

[ ] TWIC Card (195)

[ ] Other (List here or on back.)

Welding Certifications:[ ] Light Gauge (221)[ ] Wire Cert (154)[ ] TIG Cert (155)[ ] Stick Cert (156)[ ] WABO Cert (192)

Do you participate in the Western WA 401A Pension Plan? Check 4[ ] YES [ ] NOIf yes, please check 4 the appropriate amount:[ ] $1.00 [ ] $2.00[ ] $3.00 [ ] $4.00

AREA 1 - Most of Western Washington

AREA 3 - Central & Eastern Washington & Oregon, North and Southwest Idaho

AREA 4 - Southeast Idaho

AREA 5 - The State of Montana

AREA 2 - Southwest Washington & Western Oregon

MILLWRIGHT Dispatch Areas • Pacific Northwest Regional Council of Carpenters

AREA 3 (Continued)

OR - SE HARNEY MALHEUR LAKE

ID - NORTH BOUNDARY BONNER KOOTENAI BENEWAH SHOSHONE LATAH NEZ PERCE CLEARWATER LEWIS IDAHO

ID - SW ADAMS VALLEY LEMHI MINIDOKA WASHINGTON PAYETTE GEM BOISE CUSTER CANYON ADA ELMORE OWYHEE CAMAS BLAINE GOODING LINCOLN JEROME TWIN FALLS

AREA 3 (By Counties)

CENTRAL WA: CHELAN DOUGLAS GRANT KITTITAS KLICKITAT OKANOGAN YAKIMA

EASTERN WA (EW) ADAMS ASOTIN BENTON FERRY FRANKLIN GARFIELD LINCOLN PEND OREILLE SPOKANE STEVENS WALLA WALLA WHITMAN

OR - NE HOOD RIVER WASCO SHERMAN GILLIAM WHEELER MORROW UMATILLA GRANT UNION BAKER WALLOWA DESCHUTES CROOK JEFFERSON

AREA 4

ID - SE (By Counties) CLARK BUTTE JEFFERSON FREMONT MADISON TETON BONNEVILLE POWER CASSIA ONEIDA BANNOK FRANKLIN BEAR LAKE CARIBOU BINGHAM

AREA 5

MT THE STATE OF MONTANA

MIX 20/20 AUTOMATEDDISPATCH866-649-5463

Please direct any questions to PNWRCC Dispatch1-800-953-6444

sek/opeiu8aflcio/1.7.11

AREA 2 (By Counties)

SW WA WAHKIAKUM COWLITZ CLARK SKAMANIA

OR - NW CLATSOP COLUMBIA TILLAMOOK YAMHILL WASHINGTON CLACKAMAS MULTNOMAH

OR - CENTRAL (OC) POLK MARION LINCOLN BENTON LINN LANE

OR - SW (OSW) COOS CURRY DOUGLAS JOSEPHINE JACKSON KLAMATH

AREA 1 (By Counties)

WWA - CENTRAL KING

WWA - NORTH SKAGIT SNOHOMISH WHATCOM ISLAND SAN JUAN

WWA - SOUTH PIERCE THURSTON LEWIS

WWA - WEST CLALLUM JEFFERSON KITSAP MASON GRAYS HARBOR PACIFIC