UFCW LOCAL 1167 Food Membership Application

Joe Duffle, President
Matt Bruno, Secretary Treasurer
855 W San Bernardino Ave., Bloomington, CA 92316
membership@ufcw1167.org
Phone: (909) 877-5000 Ext. 3
Food Membership Application
Employee ID*
First Name*
Middle Init.
Last Name*
Date of Birth*

MonthDayYear
Date
Gender*
SSN*
Social Security Number
Address*
Apt #
Apt/Space Number
City*
State*
Zip Code*
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Registered Voter

YesNo
MarriedSingle
Full-timePart-time
Employer*
Company Name
Location/Store Number*
Location/Store Number
Job Classification*
Job Class
Department
Department
Date of Hire*

MonthDayYear
Date
Prev. Local Union #
Withdrawal Date

MonthDayYear
Date
FOR LOCAL UNION USE ONLY. Basics FOR MEMBERSHIP (check one)

Newly Initiated (01)Reinstate from Suspension (06)Admit (09)Cancel Withdrawal (10)Reinstate from withdrawal (05)Reinstate from military W/DCancel Suspension (11)
FOR LOCAL UNION USE ONLY. Industry Type (check one)

Food (1)Non-Food (2)Professional (3)Footwear (4)Packinghouse (5)Food processing (6)Fur & leather (7)Other (8)
I hereby make application for membership in the UNITED UNION and affirm that the above statements are true, and I agree that all moneys paid by me shall be forfeited and my membership declared void if they are not correct.I authorize the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION to represent me for the purposes of collective bargaining and handling of grievances, either directly or through such local union as it may duly designate.
Member's Signature*

Clear
Date Signed
UFCW LOCAL 1167 AUTHORIZATION FOR DEDUCTION OF INITIATION FEES AND UNION DUES.

UFCW Locals 135, 324, 770, 1167, 1428, 1442 and 8-GS - Retail Food and Meat Agreement.
I hereby voluntarily authorize and direct you, my Employer, to deduct on a weekly basis, from my net wages earned by me as your employee, such sums as the Southern California UFCW Local(s), United Food and Commercial Workers International Union, with whom I am affiliated during the course ofmy employment, certify are due and owing from me for the initiation fee and monthly dues uniformly required as a condition of membership in the Union, in such sums as may be established from time to time by the involved Local Union. I authorize and direct you to deduct such amounts from my net weekly pay and to remit same to the Local Union at such times and in such manner as may be agreed upon between you and the Local Union.

Thisvoluntary authorization shall take effect as of the date it is recieved by you and shall be irrevocable for the period of (1) Year from the date of delivery to you, or until the termination of the Retail Food and Meat Agreement which is in force at the time of delivery of this authorization, whichever occurs sooner.

This authorization and assignment is voluntarily made in consideration of the cost of representation and collective bargaining and is not contingent upon my present or future membership in the Union. This voluntary authorization may be revoked by me at any time after one (1) year following its effective date by my giving thirty (30) days written notice to my Employer and the Union or at such time as my job classification changes to a classification that is not covered by the Collective Bargaining Agreement, or upon my termination from employment with my Employer.

I understand that the Union shall indemnify and hold harmless my Employer against any and all claims, damages or suits or other forms of liability or expenses which may arise out of or by reason of any action taken by the Employer for the purpose of complying with this authorization.
Name

First NameLast Name
DATE

MonthDayYear
Date
Store Number
SSN
Social Security Number
Employee ID
Employee I.D Number
SIGNATURE

Clear
UFCW LOCAL 1167AUTHORIZATION FORM FOR POLITICAL CHECKOFF
I hereby authorize {companyName}(EMPLOYER) to deduct $1.00 dollar per week from my paycheck.

Such amount is to be remitted to UFCW Local No. 1167 on a monthly basis for transmittal to the UFCW International Active Ballot Club.

I understand that this authorization is voluntarily made and that the amount suggested as a contribution is a guideline and that I may contribute more or less than this amount by any lawful means, other than this checkoff, or may refuse to contribute and that the making of payments to the UFCW Active Ballot Club is not a condition of membership in the Union or of employment with the Employer and that I have a right to refuse to sign this authorization and not contribute to the UFCW Active Ballot Club without reprisal.

I understand that my contribution will be used for political purposes, including the support of candidates for federal, state, and local offices. I expressly reserve the right to revoke at any time this authorization in writing.

I also understand that contributions or gifts to the UFCW Active Ballot Club are not deductible as charitable contributions for federal tax purposes.
Name

First NameLast Name
Employer
Company Name
DATE

MonthDayYear
Date
SSN
Social Security Number
Employee ID
Employee ID Number
Store #
SIGNATURE

Clear
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Food Membership Application

UFCW LOCAL 1167 AUTHORIZATION FOR DEDUCTION OF INITIATION FEES AND UNION DUES.

UFCW LOCAL 1167AUTHORIZATION FORM FOR POLITICAL CHECKOFF