Application for Membership/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.

First Name

Middle Name

Last Name

Home Address

Home Address 2

Home City/Town

Home State/Province

Home ZIP/Postal Code

Employer

Worksite Address

Worksite Address 2

Worksite City/Town

Worksite State/Province

Worksite ZIP/Postal Code

Department

Classification

Cell Phone

Work Phone

Personal Email Address

Signature

Sign above

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