Phone Bank and Labor Walk Voucher Form

Name

Street Adress

City

State

Zip code

Is this a new address?

YesNo

Phone Number

Email

Are you a member of HPAE?

YesNo

If yes, which HPAE local/facility?

5004 - Englewood Hospital and Medical Center5030 - Hackensack UMC Palisades5030 - Quest Diagnostics5058 - Jersey Shore University Medical Center5089 - Rutgers University5089 - University Hospital5091 - New Bridge Medical Center5091 - The Harborage5094 - Rowan University5094 - Rutgers University5094 - University Hospital5097 - The Harborage5103 - American Red Cross5105 - Virtua Memorial Hospital5106 - Temple Episcopal Hospital5112 - Cornerstone Behavioral Health Hospital of Union County5118 - Cooper University Hospital5131 - Inspira Health - Vineland, Elmer & Bridgeton5138 - Southern Ocean Medical Center5142 - Memorial Hospital of Salem County5147 - Hudson Regional Hospital5185 - Bayonne Medical Center5186 - Christ Hospital5621 - Cooper University Hospital5621 - Inspira Health - Mullica Hill & Woodbury5621 - Inspira Health - Vineland, Elmer & Bridgeton8071R - Council of Retirees5107 - Llanfair House Care & Rehabilitation Center5107 - The Phoenix Center for Rehabilitation and Pediatrics5107 - Visiting Nurse Association of Englewood5107 - VNA Health Group of New Jersey LLC5629 - Sunrise House

Please select which activity you participated in:

In-person phone bankVirtual phone bankLabor walk

Location

Via ZoomAtlantic/Cape May CLCBergen CLCBurlington CLCEssex/West HudsonHudson CLCMercer CLCMiddlesex/SomersetMonmouth/Ocean CLCNorthwest CLC-IBEW 102Northwest CLC-IBEW 1158Southern CLC-Camden CountyCumberland CountyGloucester CountyUnion CLC

Date

September 24October 1October 3October 6October 8October 10October 13October 15October 17October 20October 22October 24October 27October 29October 31November 3November 5November 7November 8

Shift Completed (if you completed more than one shift you will need to complete this form for each shift)

MorningAfternoonEvening

Amount owed for this shift

$50