Teamsters Local 177
Teamsters Local 177

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Withdrawal Card Request

Withdrawal Card Request Form

Advisory on Withdrawal Cards

Members not working at the craft for a complete calendar month for reasons other than sickness or injury may request and be issued an Honorable Withdrawal Card in accordance with Article XVIII of the International Constitution.

Members off work for a complete calendar month because of sickness or injury should contact the Union office regarding the issuance of a withdrawal card.

Please note that any member who is not required to request a withdrawal card in accordance with the International Constitution but who requests and is issued a withdrawal card must be advised that the issuance of that withdrawal card may result in a break in their twenty-four Month continuous standing requirements of eligibility to:

  • Hold local union office.
  • Be a delegate/alternate Delegate to the next International Convention
  • Be a candidate to run for International Union office; and
  • Nominate/vote in the election of Union officers; the election of Delegates/Alternates; or, in the election of International Union officers
  • Any other continuous good standing requirements of Local Union No. 177 as stated in the Local Union Bylaws

If you are unsure if you qualify for a Withdrawal Card, or if you are BEHIND ON DUES already, please contact the Union Hall at 973-923-7070 BEFORE filling out this form in its entirety. 

First Name:
Last Name:
City, State:
,  *
Zip Code:


SSN (Last 4 Digits):*

UPS ID Number (if applicable)

Reason for Leave: (Check One) *

 Family Medical Leave Act (FMLA)
 Worker's Compensation

Last Day Worked: *

(Date Format: xx/xx/xxx Example: 01/02/2021)

Estimated Return to Work Date: (if applicable) 

(Date Format: xx/xx/xxx Example: 01/02/2021)

Additional Comments:

Electronic Signature:*

Full Name


Use your mouse, finger, or touch device to write your signature.

Enter the text shown in the image above.

* Required Fields

By clicking "Submit" and filling out the Electronic Signature box you hereby certify that all information provided as part of this application is true and correct to the best of your knowledge and is being filled out by the named applicant. You therefore also give consent to Teamsters Local Union 177 to use the information provided herein for the purpose of changing from an Active Status to Withdrawal Status. 


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