Local 2006 Membership Form

First Name

Middle Initial

Last Name

Address

Address 2

City

State

Postal Code

Employer

Job Title

Department

Work Site

Employee ID

Date of Hire

Personal Email

Home Phone

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 by calling the Union at (213) 880-7456.

Authorization

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.

Signature

Sign above