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

State Agency

Agency Location

Official Job Title

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.