Local 2006 Membership Form

AFSCME Membership

I hereby apply for membership in an associated Local of AFSCME Council 36 (hereafter referred to as the “Union”) and I agree to abide by its Constitution and Bylaws. By this application I authorize the Union, and its successor or assign, to act as my exclusive bargaining representative for purposes of collective bargaining with respect to wages, hours and other terms and conditions of employment with my employer.

Effective immediately, I hereby voluntarily authorize and direct my Employer to deduct from my paycheck regardless of whether I am or remain a member of the Union, the amount of dues certified by the Union, and as they may be adjusted periodically by the Union. I further authorize my Employer to remit such amount monthly to the Union.

This voluntary authorization and assignment shall be irrevocable, regardless of whether I am or remain a member of the Union, for a period of one year from the date of execution or until the termination date of the memorandum of understanding (if there is one) between the Employer and the Union, whichever occurs sooner, and for year to year thereafter, unless I give the Employer and the Union written notice of revocation not less than ten (10) days and not more than twenty (20) days before the end of any yearly period; provided however that any conflicting membership and deduction provisions of the applicable governing body and memorandum of understanding specifies a different or longer annual revocation period, then only that other period shall apply. The applicable memorandum of understanding is available for review, upon request. This card supersedes any prior check-off authorization card I signed.

I recognize that my authorization of dues, deductions, and the continuation of such authorization from one year to the next, is voluntary and not a condition of my employment.

Payments to the Union are not deductible as charitable donations for federal income tax purposes. However, they may be tax deductible as ordinary and necessary business expenses.

Local

First Name *

Last Name *

Middle Initial

Employee ID#

Home Phone

Cell Phone *

Personal Email *

Employer *

Department

Job Title

Hire Date

Month

Day

Year

Opt-in to updates from AFSCME

Yes

Date *

Month

Day

Year

AFSCME PEOPLE (Public Employees Organized to Promote Legislative Equality)

I hereby authorize my employer and associated agencies to deduct each pay period the amount certified as a voluntary contribution to be paid to the treasurer of American Federation of State, County, and Municipal Employees PEOPLE, AFSCME, AFL-CIO, P.O. Box 65334, Washington D.C. 20035-5334, to be used for the purpose of making political contributions and expenditures. My contribution is voluntary, and I understand that it is not required as a condition of membership in any organization, or as a condition of continued employment, and is free of reprisal. I understand that any contribution guideline is only a suggestion and I am free to contribute more or less than that amount and will not be favored or disadvantaged due to the amount of my contribution or refusal to contribute, and that I may revoke this authorization at any time by giving written notice.

In accordance with federal law, AFSCME PEOPLE will accept contributions only from members of AFSCME and their families. Contributions or gifts to AFSCME PEOPLE are not deductible as charitable contributions for federal tax purposes.

This is a voluntary contribution towards the AFSCME political fund. It is not required to join a Local of AFSCME District Council 36.

Deduction per pay period

$4.17 MVP

$ 5.00 MVP

Other Amount

Would you like an AFSCME Jacket (with minimum $4.17 per pay period contribution)?

Yes

No

If yes, please select your size

Local 2006 - Professional Medical Unit

Local 2006 Membership Form