Pennsylvania Federation of Injured Workers
P. O. Box 313
Shillington, PA 19607
Application for Membership
PLEASE PRINT OR TYPE
Name_____________________________________________________________
Mail Address_____________________________________________________
County__________________________Zip______________________________
Day Time Phone_______________Evening Phone_______________________
I am: [ ] An injured worker.
[ ] Family member or friend of an injured worker.
[ ] Supporter of the Federation of Injured Workers
I agree to support the rights of the injured workers to receive the benefits guarnanteed by law; to work with other injured workers to overcome the challenge presented by the workers' compensation system; and to work with the Pennsylvania Federation of Injured Workers by helping injured workers deal with their physical and emotional needs.
Signature___________________________________Date________________
Membership of twelve dollars ($12.00) good for an annual membership.
[ ] I am applying for the hardship fund.
