SDHSA MEMBERSHIP CANCELLATION FORM (Required)
Instructions: THIS CANCELLATION MUST BE SUBMITTED ONLINE. A Member must completely fill out, sign and date this SDHSA Cancellation of Membership Form and click on the SUBMIT button at the bottom for it to become effective. Cal. GC § 1157.10(g).
UCSD Employee ID #
Primary Phone Number
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Reason(s) for Cancellation (Optional)
We would appreciate it if you would provide a short explanation of your reason(s) for cancelling your Membership in SDHSA (which is responsible for you receiving annual pay increases and over $6,000 in extra “Stipends” every year). In particular, we would like to know if you were solicited to do so by University of California Personnel or known anti-union organizations.
Terms & Conditions
I certify that I am currently a member in good standing of the San Diego House Staff Association (the “Association”) and that I hereby submit this form to SDHSA to cancel my Membership in the SDHSA. I further understand that in doing so, I hereby explicitly waive any and all rights, benefits and privileges that are associated with Membership in the Association. Please see Benefits outlined on SDHSA’s website (www.sdhousestaff.org). UCSD has stated that they may take two to four weeks to process this cancellation and cease the collection of Membership Dues. Accordingly, I understand that the SDHSA shall not be responsible for any failure by UCSD to timely process a cancellation request and furthermore, I agree that any issues or disputes between myself and the SDHSA are required to be addressed and resolved pursuant to the explicit the terms of the then current SDHSA Membership Policies and Procedures. If you have any questions, please direct them to SDHSA C/O Mirowski & Associates, firstname.lastname@example.org with a copy to SDHSA@health.ucsd.edu.
Date Signed and Submitted
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