AFSCME Local 1004 Membership Card

YES! I choose to be a union member. I support advocating for quality service and good jobs. I understand that by becoming a union member I will make our union stronger to protect jobs, public service employees, and the services we provide!

First Name

Middle Initial

Last Name

Birthdate

Employer

Employee Number

Occupation/Job Title

Work Phone

Worksite

Shift

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 at https://www.afscme.org/tcpa.

Home Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Authorization

I hereby apply for membership in AFSCME Local 1004 and I agree to abide by its Constitution and Bylaws. By this application, I authorize AFSCME Local 1004 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 AFSCME Local 1004, and as they may be adjusted periodically by the Union. I further authorize my Employer to remit such amount monthly to AFSCME Local 1004. This voluntary authorization and assignment is revocable by providing the Union and my Employer written notice of revocation not less than ten (10) days and not more than twenty (20) days before the yearly anniversary of the signing of this membership card, unless an applicable collective bargaining agreement imposes other limitations. The applicable collective bargaining agreement (if there is one) 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

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.

Printed Name

Date