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

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Employer

Job Title

Department

Employee Number

Date of Hire

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

I hereby apply for membership in the American Federation of State, County and Municipal Employees, [Council XX], [Local XXXX], AFL-CIO (hereafter "AFSCME [Council XX], [Local XXXX]" or the "Union") and I agree to abide by its Constitution. By this application I authorize AFSCME [Council XX], [Local XXXX] and any 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 [Employer Name].

Effective immediately, I hereby voluntarily authorize and direct [Employer Name] 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 AFSCME [Council XX], [Local XXXX] and as they may be adjusted periodically by the Union. I further authorize [Employer Name] to remit such amount bi-weekly to the Treasurer of AFSCME [Council XX].

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 of this authorization or until the termination date of the collective bargaining agreement (if there is one) between [Employer Name] and the Union, whichever occurs sooner, and for the years to come, unless I give [Employer Name] and the Union written notice of revocation during the fifteen (15) days before the annual anniversary date of this authorization, or termination of the collective bargaining agreement.

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 AFSCME [Council XX], [Local XXXX] 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.