SRS GLOBE Membership Initial Application
Membership is open ONLY to employees of the Savannah River Site.

Note: All membership information is kept strictly confidential and will not be distributed or released without prior written consent.  Aggregate data will be compiled in order to provide answers about the membership that may be posed by the SRS Federal or Contractor management.

First Name:    Last Name:

City:    State:     Zip:

Work Phone:(for verification only)
Home Phone:    Cell Phone:

Email Address (non-SRS):
How did you learn about the SRS-GLOBE organization:
Were you referred by an existing GLOBE member?
           If so, please provide their name:

Employer:

Job Title/Function:
Shift Schedule (Days, AA,BB, 4/10s, etc):
Are you "out" at work? Yes        No
Are you "out" to family/Friends?  Yes        No
Preferred Meeting Day of Week:         Time of day:

Please rank the following issues (1=most important,   5=least important):
1. Company recognition of SRS GLOBE Employee Organization 
2. Soft Domestic Partner benefits (sick Leave, Death in Family,etc):
3. Hard Domestic Partner benefits (Health Coverage, Survivor Benefits):
4. On Site June Pride Recognition Event:
5. On Site Meetings:
6. Other: