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A&R Membership Card & Checkoff v2
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First Name
Last Name
Employee #
Home Mailing Address
Mobile #
Home e-mail
Home Phone #
Work Phone #
Date of Birth
Gender
Male
Female
State Agency
- Select -
Auditors of Public Accounts
Board of Ed and Services for the Blind
Community College - Capital
Commission on Human Rights
Community College - Asnuntuck
Community College - Housatonic
Community College - Manchester
Community College - Middlesex
Community College - Naugatuck
Community College - Northwestern
Community College - Norwalk
Community College - Quinebaug
Community College - Three Rivers
Community College - Tunxis
Community Colleges Board of Trustees
Connecticut Agricultural Experiment Station
Connecticut Airport Authority
Connecticut Development Authority
Connecticut Housing Finance Authority
Connecticut Lottery Corporation
Connecticut Siting Council Office
Connecticut State Library
Connecticut State University - Central
Connecticut State University - Eastern
Connecticut State University - Souther
Connecticut State University - System Office
Connecticut State University - Western
Department of Administrative Services
Department of Agriculture
Department of Banking
Department of Children and Family
Department of Consumer Protection
Department of Corrections
Department of Developmental Services
Department of Education
Department of Environmental Protection
Department of Higher Education
Department of Housing
Department of Information Technology
Department of Insurance
Department of Labor
Department of Mental Health and Addiction
Department of Motor Vehicles
Department of Public Health
Department of Public Safety
Department of Public Utility
Department of Revenue Services
Department of Social Services
Department of Transportation
Department of Veterans Affairs
Economic and Community Development
Elections Enforcement Commission
Ethics Commission
Freedom of Information Commission
Military Department
Office of Attorney General
Office of Chief Medical Examiner
Office of Child Advocate
Office of Consumer Council
Office of Ealy Childhood
Office of Governmental Accountability
Office of Health Strategy
Office of Healthcare Advocate
Office of Policy and Management
Office of State Comptroller
Office of State Treasurer
Office of the Claims Commissioner
Office of Victim Advocate
Secretary of the State
State Board of Accountancy
Teachers' Retirement Board
University of Connecticut
University of Connecticut - Health Center
Workers Compensation Commission
Department of Aging
DESPP
Other - Not In This List
Agency Location
- Select -
Andover
Ansonia
Ashford
Avon
Barkhamsted
Beacon Falls
Berlin
Bethany
Bethel
Bethlehem
Bloomfield
Bolton
Bozrah
Branford
Bridgeport
Bridgewater
Bristol
Brookfield
Brooklyn
Burlington
Canaan
Canterbury
Canton
Chaplin
Cheshire
Chester
Clinton
Colchester
Colebrook
Columbia
Cornwall
Coventry
Cromwell
Danbury
Darien
Deep River
Derby
Durham
East Granby
East Haddam
East Hampton
East Hartford
East Haven
East Lyme
East Windsor
Eastford
Easton
Ellington
Enfield
Essex
Fairfield
Farmington
Franklin
Glastonbury
Goshen
Granby
Greenwich
Griswold
Groton
Guilford
Haddam
Hamden
Hampton
Hartford
Hartland
Harwinton
Hebron
Kent
Killingly
Killingworth
Lebanon
Ledyard
Lisbon
Litchfield
Lyme
Madison
Manchester
Mansfield
Marlborough
Meriden
Middlebury
Middlefield
Middletown
Milford
Monroe
Montville
Morris
Naugatuck
New Britain
New Canaan
New Fairfield
New Hartford
New Haven
New London
New Milford
Newington
Newtown
Norfolk
North Branford
North Canaan
North Haven
North Stonington
Norwalk
Norwich
Old Lyme
Old Saybrook
Orange
Oxford
Plainfield
Plainville
Plymouth
Pomfret
Portland
Preston
Prospect
Putnam
Redding
Ridgefield
Rocky Hill
Roxbury
Salem
Salisbury
Scotland
Seymour
Sharon
Shelton
Sherman
Simsbury
Somers
South Windsor
Southbury
Southington
Sprague
Stafford
Stamford
Sterling
Stonington
Stratford
Suffield
Thomaston
Thompson
Tolland
Torrington
Trumbull
Union
Unknown
Vernon
Voluntown
Wallingford
Warren
Washington
Waterbury
Waterford
Watertown
West Hartford
West Haven
Westbrook
Weston
Westport
Wethersfield
Willington
Wilton
Winchester
Windham
Windsor
Windsor Locks
Wolcott
Woodbridge
Woodbury
Woodstock
Other
Official Job Title
- Select -
Accountant
Accounting Careers Trainee
Accounting Specialist
Accounts Examiner
Adjudicator
Administrative Hearings Attorney 1
Administrative Hearings Attorney 2
Administrative Hearings Specialist
Administrative Specialist (Real Estate)
Administrative Specialist (Social Compliance)
Agriculture Marketing and Inspection Representative 1
Agriculture Marketing and Inspection Representative 2
Agriculture Marketing And Inspection Supvr
Airport Manager 1
Airport Operations Assistant Specialist
Airport Operations Coordinator 2
Airport Operations Specialist
All Affected
Assistant Accountant
Assistant Adjudicator
Assistant Cash Control Officer
Assistant Director of Operations
Assistant Director of State Fleet Operation
Assistant Economic And Community Development Agent
Assistant Investment Officer (rc)
Assistant Investment Officer Social Compliance (rc)
Asst Planning Director
Assistant Rate Specialist (Public Utilities)
Associate Accountant
Associate Accounts Examiner
Associate Economist
Associate Financial Examiner
Associate Fiscal/Administrative Officer
Associate Fiscal/Administrative Officer (Unclassified)
Associate Health Care Analyst
Associate Rate Specialist
Associate Research Analyst
Associate Research Analyst (rc)
Associate Research Attorney
Associate Retirement and Benefits Officer
Associate Revenue Processor (Administrative Services)
Associate Revenue Processor (Revenue Services)
Associate Sales Assessment Ratio Field Representative
Associate Staff Attorney to Employment Security Board of Review
Associate Tax Inheritance Examiner
Associate Utilities Operations Analyst
Attorney For The Office Of Protection And Advocacy
Banking Administrative Attorney 1
Banking Administrative Attorney 2
Banking Asst Div Director
Banking Associate Examiner (General)
Banking Associate Examiner (Securities)
Banking Dept Mgr
Banking Education Coordinator
Banking Principal Examiner (General)
Banking Principal Examiner (Securities)
Boiler Inspector
Bookstore Assistant Supervisor
Bookstore Supervisor 1
Bookstore Supervisor 2
Braille Coordinator
Claims Analyst
Claims Supervisor
Collection Services Investigator (RC)
Collection Services Investigator Supervisor (RC)
Collection Services Manager 1 (RC)
Commercial Recording Assistant Manager
Communications Officer (RC)
Communications Specialist (RC)
Community Development Specialist
Community Development Specialist (rc)
Compensation Review Board Chief Law Clerk
Connecticut Careers Trainee (Administrative & Residual)
Connecticut Marketing Authority Business Services Officer
Consumer Counsel Supervisor Of Utility Financial Analysis
Consumer Information Representative
Consumer Protection Assistant Division Director
Consumer Protection Assistant Division Director (Fraud)
Consumer Protection Assistant Division Director (Professional Tra
Consumer Protection Assistant Division Director (Real Estate)
Consumer Protection Automotive Technical Expert
Consumer Protection Inspector (Athletics)
Consumer Protection Inspector (Food)
Consumer Protection Inspector (Product Safety)
Consumer Protection Inspector (Professional Trades)
Consumer Protection Inspector (Weights and Measures)
Consumer Protection Lead Real Estate Examiner
Consumer Protection Licensing Supervisor
Consumer Protection Licensing Supervisor (rc)
Consumer Protection Real Estate Examiner
Consumer Protection Supervisor (Central Licensing)
Consumer Protection Supervisor (Food)
Consumer Protection Supervisor (Product Safety)
Consumer Protection Supervisor (Professional Trades)
Consumer Protection Supervisor (Real Estate)
Consumer Protection Supervisor (Trade Practices)
Consumer Protection Supervisor (Weights and Measures)
Contract Analyst
Contract Specialist
Contract Team Leader
Correctional Industries Sales Representative
Demhs Fusion Center Analyst
Demolition And Crane Operations Inspector
Developmental Services Program Development Coordinator (rc)
Director Of Volunteer Services
Disability Retirement Coordinator
DOL Unit Manager
DMSSSM
Economic And Community Development Agent
Economic Development Assistant Division Director (rc)
Economist
Elections Enforcement Commission Staff Attorney 1
Elections Enforcement Commission Staff Attorney 2
Elections Officer
Elevator Inspection Supervisor
Elevator Inspector
Emergency Management Area Coordinator
Emergency Management Program Specialist
Emergency Management Program Supervisor
Emergency Management Radiological Equipment Maintenance Officer
Emergency Medical Services Field Program Coordinator
Emergency Medical Services Supervisor
Emergency Medical Services Training Coordinator
Energy & Environmental Protection Supervisor Of Education
Environmental Education Coordinator
Environmental Protection Education And Firearms Safety Coordinato
Environmental Protection Indian Affairs Coordinator
Environmental Protection Program Specialist 1
Environmental Protection Safety Representative (Boating Safety)
Environmental Protection Safety Representative (Firearms Safety)
Equities Trading Assistant
Erp Financials Business Analyst
Erp Financials Business Specialist
Erp Financials Business Team Lead
Ethics Commission Staff Attorney 1
Ethics Commission Staff Attorney 2
Financial Examiner
Fire Service Analyst
Fiscal/Administrative Assistant
Fiscal/Administrative Assistant (Unclassified)
Fiscal/Administrative Officer
Fiscal/Administrative Officer (Unclassified)
Fiscal/Administrative Supervisor
Fiscal/Administrative Supervisor (Unclassified)
Fiscal/Administrative Manager 1
Fiscal/Administrative Manager 2
Fleet Manager (RC)
Fleet Operations Safety Coordinator
Fleet Repairs Supervisor
Forensic Fraud Examiner
Freedom of Information Commission Appellate Attorney (RC)
Freedom Of Information Commission Staff Attorney 1
Freedom Of Information Commission Staff Attorney 2
Grants And Contracts Manager
Handicapped Driver Training Consultant
Health Care Advocate Prg. Manager
Health Care Analyst
Health Services Medical Quality Assurance Supervisor
Historic Sites Researcher
Housing Specialist 1
Housing Specialist 2
Humanities Program Coordinator
Insurance Accredited Financial Examiner
Insurance Actuary
Insurance Associate Examiner
Insurance Associate Examiner (Examination and Market Conduct)
Insurance Certified Financial Examiner
fiInsurance Certied Supervising Examiner
Insurance Certified Supervising Examiner
Insurance Examiner
Insurance Examiner (Examination and market conduct)
Insurance Financial Examiner
Insurance Holding Co Exam
Insurance Principal Examiner
Insurance Principal Examiner (Examination and Market Conduct)
Insurance Program Manager
Insurance Supervising Examiner (Examination)
Interstate Revenue Examiner
Investment Accounting Analyst
Investment Officer - Social Compliance (rc)
Investment Operations Officer
Investment Technician 1
Investment Technician 2
Labor Dept Unit Mgr
Labor Relations Research Assistant
Law Enforcement Systems Anayst
Law Librarian
Lead Boiler Inspector
Lead Consumer Information Representative
Lead Economic Development Agent (RC)
Lead Legal Investigator
Lead Placement And Training Program Analyst
Lead Planning Analyst
Lead Rate Specialist
Lead Special Investigator (general)
Lead Special Investigator (Medical Examiner)
Lead Training Coordinator
Legal Investigator
Legal Services Developer
Legislative And Regulations Analyst
Legislative And Regulations Specialist
Legislative Services Advisor (RC)
Librarian
Librarian 1 - State Library
Librarian 2 - State Library
Library Specialist
Library Technical Assistant
Library Technician
License And Applications Analyst
License And Applications Specialist
License And Applications Supervisor (rc)
Licensing Examination Assistant
Litigation Attorney, Office of Consumer Counsel
Lottery Financial Analyst
Lottery Media And Marketing Specialist (RC)
Lottery Specialist
Lottery Specialist
Maintenance Manager
Management Analyst 1
Management Analyst 2 (rc)
Management Analyst 3
Medical Records Supervisor 1
Medical Records Supervisor 2
Mental Health Assistant Director of Program Management Services
Mental Health Services Administrative Intern
Mental Health Services Assistant Manager
Motor Vehicle Analyst
Motor Vehicle Branch Manager 1
Motor Vehicle Branch Manager 2
Motor Vehicle Branch Operations Supervisor 1
Motor Vehicle Driver Improvement Analyst
Motor Vehicle Driver Improvement Analyst Supervisor (rc)
Motor Vehicle Driver Improvement Assistant
MV Hub Branch Manager
Motor Vehicle Legal Services Analyst
Motor Vehicle Legal Services Specialist
Motor Vehicle Program Coordinator
Museum Curator 1
Museum Curator 2
Museum Director
National Register Specialist (Archaeologist)
National Register Specialist (Architectural Historian)
National Register Specialist (Historian)
Occupational Hygienist
Occupational Safety And Health Officer
Occupational Safety Officer
Occupational Safety Training Specialist
Off Track Betting Manager 1
Paralegal Specialist
Paralegal Specialist 1
Paralegal Specialist 1 (Unclassified)
Paralegal Specialist 2
Paralegal Specialist Trainee
Payroll Officer 1
Payroll Officer 2
Payroll System Coordinator
Payroll System Supervisor
Penalty Waiver Officer
Pension Fund Accountant
Pension Funds Analyst
Placement And Training Program Analyst 1
Placement And Training Program Analyst 2
Planning Analyst
Planning Analyst
Planning Analyst Supervisor
Planning Specialist
Preservation Programs Supervisor
Primary Prevention Services Coordinator
Principal Adjudicator (RC)
Principal Attorney (rc)
Principal Cost Analyst
Principal Financial Examiner
Principal Health Care Analyst
Program Assistant - Commission On The Arts
Program Associate - Commission On The Arts
Program Specialist-Commission On The Arts
Property Coordinator
Property Management Liaison
Public Records Grant Program Specialist
Public Utilities Administrative Hearings Coordinator
Public Utilities Support Services Assistant Supervisor (rc)
Public Works Assistant Director Of Facilities Operations
Public Works Legal Services Staff Attorney
Purchasing and Store AD
Purchasing Inspector
Purchasing Services Officer 1
Purchasing Services Officer 2
Purchasing Services Officer 3
Quality Assurance Coordinator
Quality Of Life Monitor
Quality Of Life Monitor (rc)
Rate Specialist
Real Estate Examiner
Records And Legislative Services Assistant Coordinator
Reimbursement Analyst
Reimbursement Team Leader
Reinsurance Specialist
Research Analyst
Research Analyst (Unclassified)
Research Analyst Supervisor
Research Assistant
Research Attorney
Retirement And Benefit System Coordinator
Retirement And Benefits Officer
Revenue Agent 1
Revenue Agent 2
Revenue Agent 3
Revenue Examiner 1
Revenue Examiner 2
Revenue Examiner 3
Revenue Examiner 4
Revenue Processor (Administrative Services)
Revenue Processor (Revenue Services)
Revenue Services Administrative Support Specialist (rc)
Revenue Services Internal Control Officer
Revenue Services Tax Supervisor
Safety Program Officer
Sales Assessment Ratio Field Representative
Secretary Of The Connecticut Historical Commission
Securities Analyst
Senior Program Associate - Commission On The Arts
Special Investigator (General)
Special Investigator (Medical Examiner)
Special Investigator (Non-Competitive)
Special Revenue Charitable Games Liaison Officer
Special Revenue Division Judge
Special Revenue Gambling Facilities Liaison Officer
Special Revenue Gambling Regulation Facility Supervisor
Special Revenue Investigator
Special Revenue Lead Gaming Liaison Officer
Special Revenue Lead Investigator
Special Revenue Licensing Coordinator
Special Revenue Lottery Claims Supervisor
Special Revenue Lottery Specialist
Special Revenue Marketing Coordinator
Staff Attorney 1
Staff Attorney 2
Staff Attorney 3
Staff Attorney To The Employment Security Board of Review
State Archivist
State Library Unit Head
State Police Message Center Supervisor
State Resource Library Specialist
StateInnvtnModelSpec
Statistician
Supervising Accountant
Supervising Accounts Examiner
Supervising Adjudicator
Supervising Attorney State Ethics Commission
Supervising Special Investigator
Supervisor Of Education, Safety And Health Services
Supervisor Of Education, Safety And Health Services (rc)
Supervisor Of Food Processing
Supervisor Of Mail, Duplicating, And Courier Services
Supervisor Of Record Services For State Agencies
Tax Appellate Officer
Tax Appellate Specialist
Tax Attorney 1
Tax Attorney 2
Tax Attorney 3
Tax Attorney 3
Tax Collection Assistant Supervisor
Tax Collection Supervisor
Tax Corrections Examiner 1
Tax Corrections Examiner 2
Tax Corrections Principal Examiner
Tax Hearings Officer
Tax Operations Assistant Unit Supervisor
Tax Operations Unit Supervisor
354Taxpayer Advocate
Teletrack Line Supervisor
Tourism Program Associate
Tourism Program Coordinator
Tourisn Program Assistant
Trainer
Training Program Coordinator
Training Program Coordinator (RC)
Training Program Specialist
Transit Manager
Transportation Assist District Engineer
Transportation Bridge Safety Prn Engineer
Transportation Harbor Liaison Officer
Transportation Material Storage Supervisor
Transportation Public Concessions Inspector
Transportation Public Concessions Supervisor
Transportation Public Transit Inspector
Underwriter
Unemployment Compensation Field Examination Supervisor
Unknown
Utilities Assistant Finance Specialist
Utilities Examiner 1
Utilities Examiner 2
Utilities Finance Specialist
Utilities Operations Analyst
Utilities Principal Finance Specialist
Vehicle Control Supervisor
Vending Facility Supervisor
Volunteer Programs Manager
Workers Compensation Commission District Supervisor
Workers Compensation Education Coordinator
Workers` Comp Comm District Ops Supvt
Workshop Supervisor 1
Workshop Supervisor 2
Youth Systems Coordinator
None Of The Titles Listed
Date of State Hire
Date of Hire Into A&R
Salary Grade
Step
Membership Authorization
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
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.
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