ACMEA Dues Authorization

P.O. Box 29527 Oakland, California 94604-9257

ACMEA Dues Authorization
How did you learn about joining ACMEA?*

Co-workerEmail from ACMEAEmployerNew employee orientationPostal mail from ACMEAShop StewardSupervisorText message from ACMEAOther
Status*
Employer Name for AirTable*
State for Airtable*
Bargaining Unit for SmartSheet*
Your Bargaining Unit*
Status for Airtable*
First Name*
Middle Name
Last Name*
Suffix
Date of Birth*

MonthDayYear
Date
Your T-Shirt Size*
Personal Email Address:*
example@example.com
Personal Cell Number*
Area Code Fixed*
Cell Phone Fixed*
Home Address*
Street (Please only use letters and numbers - NO special characters)
City*
State*
ZIP Code*
Your Employer*
NOTE: Alameda Health System=Hospitals
Your Agency Name (Old)*
Your Agency Name*
Your Job Classification (not working title)*
Examples: Program Specialist, Inspector, Secretary.
Work Email*
example@example.com
Employee ID*
This should be 6 digits such as 001234
Hire Date (approximate)*
MM/YYYY
Promotion Date (approximate) - if applicable
MM/YYYY
Your Race: (For statistical purposes only. ACMEA has a non-discrimination policy.)*

Asian or Pacific IslanderBlack or African AmericanHispanic or LatinoNative American or Alaskan NativeWhite or CaucasianMultiracial or BiracialPrefer not to answer
Your Gender: (For statistical purposes only. ACMEA has a non-discrimination policy.)*

MaleFemaleNon-binary/third genderPrefer not to answerPrefer to self-describe, below:
New Dues Card - ACMEA
I, {namePrinted}, authorize the withdrawal of dues, assessments, and initiation fees in accordance with the ACMEA Bylaws from my biweekly paycheck. I understand my monthly dues include the following services and benefits:
- Full legal representation by the Mastagni Holstedt Law firm.
- One hour of complimentary legal advice for matters unrelated to employment or labor disputes. This includes advice in all legal fields such as Civil, Criminal, and Personal Injury.
- I will be allowed to attend ACMEA meetings and vote in ACMEA elections.
- I will be added to the ACMEA SMS/text, email, and voice messaging systems, and can opt-out at any time.
Eligible members may only join ACMEA during their initial sixty (60) days of eligibility or during open enrollment. The open enrollment begins annually on October 1 and ends on October 31 of each year, to be effective January 1 of the following year.
Employer and Agency
Name Printed*
Name Printed 2
Date

MonthDayYear
Calculation
DateTime
Date Final
Signature (use your PC mouse or finger to sign)
File Name
Signature

Clear
Reply email admin*
example@example.com
Time*

Hour Minutes

AM/PM Option
JitBit Email*
Should be Empty: