Basic information:

 Company:    Job Class:                

 Pay Rate:   Years in Industry:    Full/Part Time: _ Full Time Part Time

 Age:     Gender: _ Male Female    Marital Status: _ Married Single    Dependents:  

Job Information:

• Do you consider the grocery industry your career?                  Yes    No

•  Are you the sole provider of health benefits for your family?   Yes   No

• How do you rate the current working conditions of your present job?

         Very Good     Good      Fair     Poor  Very Poor  

• How do you rate your current health benefits?

   Very Good     Good      Fair     Poor  Very Poor  

• What is the MOST important issue in the upcoming negotiations?

rank 1-6 with 1 being the highest priority) 

_ 1 2 3 4 5 6 Health Benefits                                 _ 1 2 3 4 5 6 Working Conditions             

_ 1 2 3 4 5 6 Pension                                             _ 1 2 3 4 5 6 Hours

_ 1 2 3 4 5 6 Wages                                               _ 1 2 3 4 5 6 Vacation

·         What aspects of your working conditions do you like the best?

 ·         What aspects of your working conditions do you feel needs the most improvement?

Goals for the New Contract: 

• A wage increase of per hour is justified in each year of the new contract
   
• On the issue of healthcare benefits, do you believe (check only one)

the current plan should stay as is. 

the plan needs an overhaul.  

·         On the issue of the pension plan, do you believe (check only one) 

the current plan should stay as is.  

the plan needs an overhaul. 

• Are there other improvements you would like to see on the new contract?

• What is the top priority in negotiations other than the issues discussed?

 WHAT ARE YOU WILLING TO DO TO GET A BETTER CONTRACT?

Come to special contract meetings

Distribute material to my co-workers

Wear a union button

Attend union rallies

Become a shop steward

Receive training to be a media spokesperson

Write letters to the local newspapers

Be a picket captain (if there is a labor dispute)

Be on negotiation committee 

Other (please specify) 

 I am ready to help my union get a better contract by:

First Name: Last Name:

Street:

 City:    State:   Zip:

Phone:     Company/Store number:

 Email Address: