IBEW Local 1205

Member Information UPDATED

IBEW Local Union 1205 Information Form

We are an Equal Opportunity Employer. It is our policy to abide by all Federal, State and Local laws concerning discrimination in employment. No question in this
application is intended to elicit information in violation of any such law nor will any information obtained in response to any question be used in violation of any such
law.

**Please type NA in any text field for which no information is available.

Please use the date of this submission as my initiation date with IBEW Local Union 1205. I understand I will begin paying monthly dues the month immediately following the month of this submission and I also acknowledge a $2.00 IBEW pension admission fee will be added to my account as of today's date.

How did you hear about us? Please provide the name of any individual you have been in contact with regarding our organization.

Position applying for/current classification:

Additional information for those applying for Inside Journeyman Wireman:

Qualifications for becoming an Inside Journeyman Wireman with IBEW.

Completion certificate from a federally registered apprenticeship program (optional)
Journeyman License (optional)
At least 5 years provable work history in the electrical trade (forms of proof are typically an IRS transcript, W2s, check stubs, or Social Security Print out)
More than five years' work history will benefit your application

IRS records can be obtained by request through the agency's website.

These documents should be attached to this submission. Once received, a representative will contact to set up an interview with the Examining Board.

The Examining Board meets by appointment only on the second Friday of each month at the IBEW Local Union 1205 office located at 2510 NW 6th Street, Gainesville, FL 32609. A minimum of a week's notice is required to review paperwork and set up your interview. Hands-on testing as well as a written test may be required at the time of your interview. Three hours of time are allocated for each portion of the test. Testing begins at 9AM EST and concludes around 4PM EST. Please plan accordingly.

Are you able to perform the job(s) for which you are applying?:

First Name:

Last Name:

Middle Name:

First Five of Social Security Number:

Date of Birth (MM/DD/YYYY):

Email:

Phone(555-555-5555): (By including your mobile number you are authorizing the IBEW Local 1205 to call you and get text alerts to you occasionally. We will never charge you for text message alerts but carrier message fees and data rates may apply. Reply STOP to any text from us to stop receiving messages or reply HELP for more information.)

Is it ok to text this number?:

Street Address:

City:

State:

Zip:

County:

In case of an accident, please notify (Name, relationship, and phone number):

List the name and relationship of any relatives or friends who are members of this organization:

Have you been convicted of a crime in the past 10 years, excluding misdemeanors and summary offenses, which has not been annulled, expunged, or sealed by a court? (A conviction will not necessarily be a bar to employment.):

If yes, please describe in full detail:

Can you verify your legal rights to work in the U.S. by providing a birth certificate, proof of U.S. Citizenship, or by some other means?:

Have you ever been a member of the IBEW?

If Yes

Local Union Number, City and State:

Years of previous membership:

Classification in that local:

Reason for dropping membership:

EDUCATION

High School

Name and Location:

Number of Years Completed:

Date of Graduation:

Diploma or Degree Earned:

Trade or Business School

Name and Location:

Number of Years Completed:

Date of Graduation:

Diploma or Degree Earned:

College or Graduate School

Name and Location:

Number of Years Completed:

Date of Graduation:

Diploma or Degree Earned:

Have you served an apprenticeship?

If Yes

Dates of Apprenticeship:

Trade:

Local union (if any) affiliated with the apprenticeship:

EXPERIENCE

Please list all Mechanical and/or Technical Experience and describe any and all qualifications, including any licenses held:

List present and former employers for the last 10 years beginning with the most recent. Work history documentation is required and may be uploaded to this form.

Name and location of Company:

Supervisor name and contact number:

Describe Your Work:

Last hourly wage:

Dates of employment:

Reason for Leaving:

May we contact this employer?:

Name and location of Company:

Supervisor name and contact number:

Describe Your Work:

Last hourly wage:

Dates of employment:

Reason for Leaving:

May we contact this employer?:

Name and location of Company:

Supervisor name and contact number:

Describe Your Work:

Last hourly wage:

Dates of employment:

Reason for Leaving:

May we contact this employer?:

Please provide the name and phone number and/or email of references for individuals you have worked with in the electrical trade.

Additional Remarks:

If you would like to attach documents please do so with the attach file button at the top of this form.

IBEW/NECA Electronic Reciprocal Transfer System(ERTS)

Home Fund Selections Defined Benefit (DB) Fund - NECA-IBEW 1205 PENSION FUND

Defined Contribution (DC) Fund - NECA-IBEW 1205 PENSION FUND

Health & Welfare Fund - NECA/IBEW FAMILY MEDICAL CARE PLAN (FMCP)

Defined Benefit/Defined Contribution Pension Fund(s)

I hereby authorize all Defined Benefit (DB) or Defined Contribution (DC) pension funds (“Participating Funds”) signatory to the Electrical Industry Pension Reciprocal Agreement (“Agreement”) that receive contributions on my behalf for hours worked within the area covered by any such Participating Fund(s) to transfer such hours and an equivalent amount of money to my properly-designated home DB and/or DC pension fund (“Home DB/DC Fund”). I also authorize my properly-designated Home DB/DC Fund to accept and apply these transferred hours and monies pursuant to the Agreement and the Home DB /DC Fund’s rules and internal administrative policies. For hours and monies transferred pursuant to this authorization I waive any claim on my behalf for benefits from a Participating Fund and release the Participating Fund(s) and its (their) trustees from any and all liability.

Health & Welfare Fund(s)

I hereby authorize all Health & Welfare (H&W) funds (“Participating Funds”) signatory to the Electrical Industry Health & Welfare Reciprocal Agreement (“Agreement”) to receive all contributions for my hours worked within the area covered by any such fund(s) and to transfer such hours to my properly-designated home health & welfare fund (“Home H&W Fund”). I also authorize my properly-designated Home H&W Fund to accept and apply these transferred hours and monies pursuant to the Agreement and the Home H&W Fund’s rules and internal administrative policies. I agree to have my eligibility and benefits determined by the rules of my Home H&W fund and that my Home H&W Fund may also require that I pay any difference in contribution rates in order to maintain coverage. I further understand and agree that I will receive the lesser amount of: 1) the contribution rate in the current Collective Bargaining Agreement (“CBA”) in effect in the jurisdiction of my Home H&W Fund or 2) the contribution amount provided in the CBA in effect in the jurisdiction of the Participating Fund. For hours and monies transferred pursuant to this authorization I waive any claim on my behalf for benefits from a Participating Fund and release the Participating Fund(s) and its (their) trustees from any and all liability. The effective date of this Authorization and Release shall be the first day of the month in which my Home Fund selection has been accepted. This Authorization and Release shall continue in full force and effect unless and until the last day of the month in which I subsequently effectuate a temporary cessation or a permanent cessation in accordance with the ERTS Agreement. I give my express consent to the IBEW/NECA Electronic Reciprocal Transfer System(ERTS) to disseminate my personal information as necessary to effectuate this Authorization and Release, including but not limited to my name, address, Social Security or Social Insurance Number, and information submitted with reciprocal transfers pursuant to the Reciprocal Agreement.

I have reviewed the Pension and Health and Welfare information above and the ERTS policy. I understand this submission serves as my electronic signature approving IBEW Local Union 1205 to register me in the Electronic Reciprocal Transfer System with IBEW Local Union 1205 funds designated for my health and welfare and pension benefits at the time my membership begins.

AUTHORIZATION FOR REPRESENTATION
I authorize Local Union No. 1205 of the International Brotherhood of Electrical Workers to represent me, as my National Labor Relations Act (NLRA) Section 9(a) bargaining representative, in collective bargaining with present and future employers on all present and future jobsites within the jurisdiction of the Union. This Authorization is nonexpiring, binding, and valid until such time as I submit a written revocation. This authorization is signed voluntarily and not out of any fear of reprisal.

APPLICANT'S CERTIFICATION - Please read carefully before submitting -
I certify that, to the best of my knowledge and belief, the answers given by me to the foregoing questions and the statements made by me are correct and complete. I understand that misrepresentation or omission of facts may result in my discharge.

Do you understand and agree to the terms above? Yes

The IBEW Local 1205 negotiates on behalf of its workers benefits that include a Health and Welfare plan at no premium cost when 140 work hours per month are maintained. Links to full plan descriptions can be found on our website. Please complete and return the enrollment form and (if applicable) the spouse employment data form to utilize these benefits.
Members of the IBEW are eligible for a death benefit after six months of membership. To name a beneficiary for this benefit, complete and return this beneficiary form.

BY CLICKING SUBMIT, YOU ACCEPT THAT YOUR PRINTED NAME, IP ADDRESS AND THE DATE AND TIME WILL BE USED AS YOUR DIGITAL
SIGNATURE FOR THE PURPOSES OF THIS FORM.

Your Full Name:

Today's Date: mm/dd/yyyy

For new members, please make sure this form has also been submitted: IBEW Application Form 107

Enter the text shown in the image above.