Print and mail coupon to: District Council 37
Political Action and Legislation
125 Barclay Street, Room 408
New York, NY 10007
Attn.: Eren Isbilir or Fax Coupon to (212) 815-1553

Last Name __________________First Name________________

Address ________________________________ Apt. # ______

City __________________ State ______ Zip Code ___________

Home Phone ( ___ ) _________ Work Phone ( ___ ) __________

Work Schedule: Days __________ Hours: From _____ To _____

Job Title _____________________ Local _________________

Agency _____________________________________________