Interest Authorization Form

Authorization for Representation

I, the undersigned, hereby designate the American Federation of State, County and Municipal Employees, 
AFL-CIO, as my duly chosen and authorized representative on matters relating to my employment in order to promote and protect my economic welfare.

Local Union Number

Home Address *

First name *

Last name *

Address 1 *

Address 2

City *

State *

ZIP code *

Employer *

Worksite

Department *

Classification *

Home Phone *

Business Phone

Personal Email *

Signature

Date *

Month

Day

Year

AFSCME District Council 36

Interest Authorization Form