Join the Union! AFT Local Union Name (hereafter referred to as "The Local") Local Number Employee Information First Name * Last Name * Middle Initial Employee Identification Number * Job Title * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Home Address * City * State * Zip Code * Non-Work Email Address * Non-Work Phone Number * Committee On Political Education By clicking "Yes" I hereby authorize my employer to deduct from my salary the sum indicated below (contribution choices will appear after if you check the authorization box after this text) per pay period and forward that amount to The Local's Committee On Political Action (COPE). This authorization is signed freely and voluntarily and not out of any fear of reprisal, and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used by AFT/COPE to make political contributions. AFT/COPE may engage in joint fundraising efforts with the AFL-CIO. This voluntary authorization may be revoked at any time by notifying The Local's COPE in writing of the desire to do so. Contributions or gifts to AFT/COPE are not deductible as charitable contributions for federal income tax purposes. Cope Authorization * Yes No Authorized COPE Contribution Amount * $1 $5 $10 $20 Other If "Other", please specify dollar amount: * Use whole numbers only. ACCEPT MEMBERSHIP * I hereby request and voluntarily accept membership in The Local and I agree to abide by its Constitution and Bylaws. I authorize The Local to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer. AUTHORIZATION FOR DUES WITHHOLDING FROM EARNINGS * I hereby request and voluntarily authorize my employer to deduct from my earnings and pay over to The Local the regular monthly dues uniformly applicable to members of The Local. This authorization will remain in effect and shall be irrevocable unless I revoke it by sending written notice to The Local during the period not less than 30 days and not more than 45 days before 1) the annual anniversary date of this agreement or 2) the date of termination of the applicable contract between the employer and The Local, whichever occurs sooner. This authorization shall be automatically renewed as an irrevocable check-off from year to year unless I revoke it in writing during the window period, irrespective of my membership in The Local. Union dues may not be deductible for federal income tax purposes; however, under limited circumstances dues may qualify as a business expense. Signature Clear signature Date * Month MonthNov Day Day17 Year Year2019 Leave this field blank
