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*

MonthDayYear
Date
Address*
Apt/Space #
City*
State*
Zip/Postal Code*
Social Security Number*
Home Phone
Cell Phone
Registered Voter

YesNo
MarriedSingle
Full-timePart-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/DCancel 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*

MonthDayYear
Date
Job Classification*
Prev. Local Union #
Withdrawal Date

MonthDayYear
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

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Date

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Date
Local Union Executive Off. Signature

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Affiliation Date

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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

MonthDayYear
Date
Date Signed

MonthDayYear
Date
Employee Signature

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