UFCW Local 1167 Drug 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

LOCAL 1167 Drug Employer
Membership Application

Emp. ID# *

First Name *

Middle Init.

Last Name *

Sex

Date of Birth *

Date

Address *

Apt/Space #

City *

State *

Zip/Postal Code *

Social Security Number *

Home Phone

Cell Phone

Registered Voter

Yes No

Married Single

Full-time Part-time

FOR LOCAL UNION USE ONLY: Basics for Membership (check one)

Newly Initiated (01) Reinstate from Suspend (06) Admit (09) Cancel withdrawal (10) Reinstate from Military W/D Cancel Suspension (11)

Industry Type (check one)

Food (1) Non-Food (2) Professional (3) Footwear (4) Packinghouse (5) ) Food processing (6) Fur & leather (7) Other (8)

Company Name *

Store Number *

City *

Date of Hire *

Date

Job Classification *

Prev. Local Union #

Withdrawal Date

Date

I hereby make application for membership in the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL 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

Local Union Executive Off. Signature

Clear

Affiliation Date

Date

PAYROLL DEDUCTION AUTHORIZATION
(Union Dues and/or Initiation Fee).

First Name

Middle Init.

Last Name

Address

Street, City, State and Zip Code

Social Security Number

Home Phone

Cell Phone

Company Name

Store Number

Job Classification

I hereby assign to UNITED FOOD AND COMMERCIAL WORKERS UNION LOCAL NO. 1167 from any wages or compensation earned or to be earned bymeas your employee such sums as may be specified to by said Union as due and owing from me as regular initiation or reinstatement fee and/or regular dues. I authorize and direct you to deduct such amounts from my pay and remit the same to the Union monthly so long as this authorization remains in effect.

This assignment, authorization and direction shall be irrevocable for the period of one (1) year from the date of delivery hereof to you, indicated below, or until the termination of the collective bargaining agreement which is now in force between your Company and the Union, whichever occurs sooner; and I further agree and direct that this assignment, authorization and direction shall be automatically renewed and shall be irrevocable for successive periods of one (1) year each or for the period of each succeeding applicable collective bargaining agreement between your Company and the (15) Union, whichever shall be shorter, unless written notice of revocation is given by me to the Company and the Union within the fifteendays immediatelypreceding the expiration of any such period of one (1) year or the termination of any applicable collective bargaining agreement between the Company and the Union, whichever occurs sooner.

Dues and/or fees paid to UFCW Local 1167 are not deductible as charitable contributions for federal tax purposes.

Hire Date

Date

Date Signed

Date

Employee Signature

Clear

Please verify that you are human *