Steward Application Form

First Name

Last Name

Membership Number

Find your Membership Number

Employer ( ie. Department, Agency, Provincial organization )

Group

Home Mailing Address

Home Address

City

Province

Postal Code

Telephone (Include Area Code)

Cell (Include Area Code)

Home E-Mail Address

Work Address (actual physical address)

Work Building

Address

City

Province

Postal Code

Telephone (Include Area Code)

Extension

Cell (Include Area Code)

Work E-Mail Address

What do you hope to accomplish as a Steward?

Nominations (Give 3 to 4 names of colleagues that support your nomination.)

Are you currently in conflict with your employer (grievance, harassment, tension, difficult communications)?

Please describe the type of conflict

I agree to serve and promote the Institute and its members to the best of my abilities, with honesty and integrity and to advance the values and mission of the Institute. I have read and understood the Guidelines for the appointment of new Stewards. I also agree to undertake PIPSC Basic Steward Training at the earliest possible opportunity.