First Name

Last Name

Membership No.

Customer Ref No. (CRN)

Email Address

Select one option only: Select one option only: Cancel Suspend Membership

Date to take affect

Reason Reason No longer working in the trade/industry Retired Unemployed Transferring interstate to work Moving overseas Other

If other why?

I agree that I will be liable for any union contributions and levies owing up to the date of cancellation of my membership. * I agree that I will be liable for any union contributions and levies owing up to the date of cancellation of my membership. * I agree that I will be liable for any union contributions and levies owing up to the date of cancellation of my membership.

I understand and acknowledge that if I put my membership on HOLD, I will not be eligible to receive membership assistance including Legal advice / Workcover support from the CFMEU * I understand and acknowledge that if I put my membership on HOLD, I will not be eligible to receive membership assistance including Legal advice / Workcover support from the CFMEU * I understand and acknowledge that if I put my membership on HOLD, I will not be eligible to receive membership assistance including Legal advice / Workcover support from the CFMEU