The following information is primarily for internal Guild use and will not be released in a manner that would identify you:
Please type or print:

Social Security #: _________________________________________________

Professional Name: ________________________________________________
(For Guild records and correspondence) Last First Middle Initial

Legal Name: ______________________________________________________
Last First Middle Initial

Pseudonym: ______________________________________________________
Last First Middle Initial

Home Address: ___________________________________________________
Street only - no P.O. Box Apt. #

___________________________________________________________________
City State Zip

Preferred Mailing Address: __________________________________

Home Phone: ( ___________ )________________________________________
Confidential ___Yes ___ No

Message Phone: ( ___________ )______________________________________
Confidential ___Yes ___ No

Fax #: ( ____________ )______________________________________________
Confidential ___Yes ___ No

Union Membership (Check if you are currently a member of):

International Guild Affiliations (Check if you are currently a member of:)
___WG Great Britain ___WG Australia ___WG New Zealand
___WG Canada ___SARDEC (French Canada) ___ASIFA
___Other(s):_________________________________________________________

Foreign Languages:________________________________________________

Which foreign language(s) do you speak and read with facility? ___________________________________________________________________

(The following information is optional. However, we strongly encourage you to complete this section, as the information allows us to accurately assess our programs to promote balanced hiring policies. This information is held confidential and only used for aggregate statistical studies.)

Date of Birth: _____________________________ Sex: ___Male ___ Female
Month Day Year

Race or Ethnic Background ___African American ___American Indian
___Asian/Pacific Islander ___ Caucasian___ Eskimo/Aleutian
___ Mexican American___ Puerto Rican___ Other Spanish Surname
___ Other (Specify)___________________________________________

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