Membership Card

YES! I am AFSCME Strong. I want a strong voice at work and in my community.

First Name

Middle Initial

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Name of Employer

Department/County

Job Class

Full Time

Part Time

Personal Email

Cell Phone †

† By providing my cell phone number I consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. My carrier’s rates may apply. I may modify my preferences at https://www.afscme.org/tcpa.

Authorization for Payroll Deduction for Union Dues

I hereby apply for membership in United EMS Workers Local 4911/AFSCME (hereafter the “Union”) and I agree to abide by its Constitution and Bylaws. 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 pay each pay period, 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, and to 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 collective-bargaining agreement (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. 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, state law may extend favored tax treatment.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.