A&R Membership Card & Checkoff v2

First Name *

Last Name *

Employee # *

Home Mailing Address *

Mobile #

Home e-mail

Home Phone #

Work Phone #

Date of Birth

Month

Day

Year

Gender

Male

Female

State Agency *

Agency Location *

Official Job Title *

Date of State Hire

Month

Day

Year

Date of Hire Into A&R

Month

Day

Year

Salary Grade

Step

Membership Authorization *

I elect to join A&R Local 4200

By checking this box, I elect to become a member of A&R Local 4200, AFT-CT, AFT, AFL-CIO. I hereby request and voluntarily accept membership in A&R Local 4200. I authorize A&R Local 4200 to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer.

Dues Deduction/Checkoff Authorization *

I authorize automatic dues deductions

By checking this box, I authorize my employer to deduct from my earnings the regular dues payable to A&R Local 4200. This authorization shall be irrevocable unless i revoke it by sending written notice via U.S. Mail to both the employer and A&R Local 4200 during the window period, February 1 -28 of any year. This authorization shall be automatically renewed from year-to-year unless revoked in writing during the window period.