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AFSCME Local 391 Website Internet

Health and Welfare Request

Use the form below to request flowers, gift baskets, etc. for Local 391 members or their family.

To download and print a request form to mail or fax, click here. To submit your request form online, fill out the form below.

Name of E-Board / Chief Steward Making Request
Email (REQUIRED FIELD)
Date of Request
Request For
Flowers Plant Fruit Basket Memorial
Reason For Request
Birth/Legal Adoption Death In Immediate Family
Injured At Home Injured At Work
If Injured At Work, Inmate Assault/Injury? Yes No
If Death In Immediate Family Please Provide Name Below
Relationship To Local's Member
If Illness Or Injury Of Union Member, Please Provide Name Of Member And His/Her Facility Below

Name:
Facility:

Address Of Person, Hospital, Funeral Home, or Charity For Donation (Please Include Telephone Numbers For Above As Well)

 
AAA Building, 2nd Floor • 109 Elm Street • Enfield, CT 06082-3719
Phone: (860) 745-0391 • Fax: (860) 745-9400
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