SUPA Membership Signup Form

SUPA Membership Application

To apply for membership please complete all questions.
Name (Your name must match with payroll ex. John Michael Lee-Smith) *

First Name Middle Initial Last Name
Social Security Number *
Enter your SSN, no dashes (i.e., 123456789)
Date of Hire *

Month Day Year
Date-Use the small calender to choose the correct date
Date of Birth *

Month Day Year
Date-Use the small calender to choose the correct date
Campus Name *
Enter your campus name
Job Classification *
(i.e., Officer, etc.)
Home Address (Do not use work address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Personal E-mail (Do not use work email) *
Home Number *

Area Code Phone Number
Cellular Number *

Area Code Phone Number
Work Number *

Area Code Phone Number
In case of emergency, please include an emergency contact for leadership to communicate with:
Emergency Contact *

First Name Last Name
Emergency Contact Number *

Area Code Phone Number
Relationship *
Spouse, Partner Etc.
Partial list of benifits:
Enrollment in PORAC LDF, covering criminal & civil matters for matters concerning course and scope of employment (i.e., officer involved shootings, deaths in custody, serious car accidents, etc…)

Representation by Law firm for all disciplinary investigations, grievances, issues concerning wages, hours, and working conditions, free legal consultations for non-work related matters, etc…)
I wish to be represented by SUPA as my sole and exclusive collective bargaining representative for all matters relating to wages, hours and other terms and conditions of employment.

I hereby apply for membership in the Statewide University Police Association (SUPA) and agree to abide by the Constitution and Bylaws and written policy of the Association at any level and authorize my employer to deduct from my salary and pay to SUPA the periodic dues or other deductions for services provided by or through SUPA. If an increase or decrease in dues or other deductions is adopted by SUPA, this authorization shall include the then-established dues or other deductions and no new authorization shall be required.

I HEREBY AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY SALARY AND PAY TO SUPA THE DUES AMOUNT INDICATED BY SUPA. I FURTHER AUTHORIZE SUPA TO REQUEST THAT MY EMPLOYER DEDUCT FROM MY SALARY THE DUES AMOUNT INDICATED BY SUPA. THIS AUTHORIZATION SHALL REMAIN IN FULL FORCE AND EFFECT UNTIL I HAVE SUBMITTED A CANCELLATION NOTICE IN WRITING TO SUPA.

*NOTE:Your SUPA membership in good standing for purposes of establishing voting rights and eligibility to hold SUPA offices will not commence until the first of the month after the first payroll deduction has been taken, unless cash payment for the interim period is remitted with this application.
By checking this box you agree to the above statement and verify that all the information entered is correct. This checkbox is used as your electronic signature. *

I agree
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SUPA Membership Application