ACMEA Dues Authorization

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

ACMEA Dues Authorization

Employer Name for AirTable *

State for Airtable *

Bargaining Unit for SmartSheet *

Status for Airtable *

Your Bargaining Unit *

First Name *

Last Name *

Suffix

Date of Birth *

Date

Personal Email Address: *

example@example.com

Personal Cell Number *

Area Code Phone Number

Home Address *

Street

City *

State *

ZIP Code *

Your Employer *

Your Agency Name *

Your Job Title *

Work Email *

example@example.com

Employee ID *

Hire Date (approximate) *

MM/YYYY

Promotion Date (approximate) - if applicable

MM/YYYY

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 free legal advice per matter with Mastagni Holstedt Law firm.
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.

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 Bargaining Unit

Name Printed

Name Printed 2

Date

Month Day Year

Calculation

DateTime

Date Final

Signature (use your PC mouse or finger to sign)

File Name

Signature

Clear