Branch 41 - 2262 Bath Avenue - Brooklyn New York 11214

PLEASE NOTE: Active members are entitled to one free voucher a year.

RETIRED MEMBERS are entitled to one free voucher every 2 (two) years.

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Please answer all questions below.
Members Last Name: Members First Name:

Members Middle Initial:

Last 4 Digits of Social Security #: Members Station

Patient's Information Name:

Please check a box below to show the relationship of the patient to the member.

daughter husband self son wife

Member's Signature___________________________ Date ____________

Click here to print this page

After filling out the above information, sign and date it then print it out and mail it to Branch 41 at the address on the top of this page. DO NOT USE A USPS POSTAGE FREE ENVELOPE. That would be illegal and we will refuse to honor the voucher request.