For your convenience, you can use your web site to obtain these forms.

Click on the link. Then print the form from the pdf document. Fill out the form and mail it to the Office. You can also fax the form to us at (626) 915-5495.

If you are unable to view PDF files, click the Acrobat Reader Icon for information on how to download a free copy of Acrobat Reader.

Grievance Form

Download Grievance Form >


UPS Grievance Form

UPS Grievance Form >


Disney Grievance Form

Download Disneyland Grievance Form >


Doctor Designation Form

Download Doctor Designation Form >


Change of Beneficiary

Just print, sign, and mail or fax to Local 495. Choose “print window” or “print to page” in your printer’s dialogue box. You can also fax the form to us at (626) 915-5495. We will contact you immediately.

Download Change of Beneficiary Form >

All information is kept confidential by the Teamsters Union and the U.S. Government

Withdrawal Card

If you leave your job, are laid-off, or if you are going to be off work due to a disability for an extended period of time, contact the Union office immediately to obtain an Honorable Withdrawal Card. You must do this within 90 days of leaving your employment.

A member who is off work and has an Honorable Withdrawal Card is not required to pay dues during this period.

Should you terminate your employment and at some future time reinstate back into Local 495 or any other Teamsters Local Union, simply redeposit your Withdrawal Card and you will not have to pay any Reinitiation Fee.

Download Withdrawal Card Form >

You must include the fee of fifty cents with your form. Contact the Office for more information.