1 Start 2 Complete Join the Union! AFT Local Union Name (hereafter referred to as "The Local") Local Number First Name Last Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Job Title Work Location Contact Information Non-Work Phone Non-Work Email Work Phone Home Address Street / P.O. Box City State ZIP 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 MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Committee On Political Education SUPPORT THE UNION’S COMMITTEE ON POLITICAL EDUCATION I hereby authorize my employer to deduct from my salary the sum indicated below (contribution choices will appear after you check the authorization box at the front of 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. Authorized COPE Contribution * $1 $5 $9 Other If "Other", Please Specify: * Signature * Clear signature Date of signature * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Leave this field blank
