APPLICATION FOR 328 RETIREES CLUB

Mail to:

UFCW Local 328 Retirees Club
278 Silver Spring Street
Providence, RI 02904-2593

Name________________________Date___________

Address_____________________________________

City__________________State_______ZIP_________

Name of Spouse_______________________________

Dues: $15.00 per person annually – payable to Local 328 Retirees Club