Local 911 Organizing Lead Form

Name of person working in a non-union shop or store:

Relationship to person completing this form (i.e. family member, neighbor, friend, etc.):

Their telephone number and address (if known):

Where they Work:

Town located in and address (if known):

Approximate number of people employed (if known):

Name of 911 member submitting information:

Are you willing to assist in an organizing campaign if one should develop?  Yes  No

If yes, please provide your home telephone number, cell phone number or e-mail address that you can be reached at: