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 * Group Life Insurance By clicking "Yes" I hereby certify that I am a new member within the last 12 months and I elect $5,000 of Group Term life Insurance which is available to me at no cost for one full year as a new AFT member. I want to be covered under the group plan for the benefits which I am or may become eligible for, as requested below. The AFT provides this insurance for one year as a benefit of AFT membership. I certify that I am actively at work. (Retirees are not eligible.) I understand the $5,000 coverage will be reduced by 50 percent at age 65 and by 75 percent at age 70. Group Life Insurance Authorization * Yes No My Beneficiary Is: * Relationship * I hereby certify that all statements and answers in this form are full, complete, and true to the best of my knowledge and belief. I understand that to be eligible for coverage I must be a new AFT member, actively working, and not currently insured under the Group Term Life Insurance plan for AFT members. In no event will I be eligible for this coverage beyond 12 months from my AFT membership date. I understand that my coverage will become effective on the first day of the month following the date this application is signed. Any person who knowingly and with intent to defraud any insurance company or other person files an AFT application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. A portion of the premium collected from the AFT Insurance program's contributory policies is allocated to fund the premium for the Policyholder's Basic Life Insurance Program. For questions, phone toll-free (888) 423-8700 or visit www.aftbenefits.org. 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 MonthMay Day Day20 Year Year2019 Leave this field blank
