OPEIU Local 40 New Member Registration & Dues Authorization Form

I, the undersigned, make application for admission to membership in the RN Staff Council, Office and Professional Employees International Union, Local No. 40 to serve as my chosen and authorized collective bargaining representative on matters relating to wages, benefits, hours and other working conditions of employment.

Name*

First NameMiddle InitialLast Name

Birthdate*

For Identification Purposes

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone*

Please enter a valid phone number.

Other Phone

Optional

Phone Carrier (ex. T-Mobile, AT&T, METRO, BOOST)

Personal Email (Cannot use employer or school domain email)*

example@example.com

Employer (hereinafter referred to as "Medical Center")*

McLaren Macomb Medical CenterAscension Providence Rochester Hospital

Date of Hire*

Shift*

Department*

Job Title*

OPEIU Local 40 Unit*

McLaren Macomb Registered Nurse UnitMcLaren Macomb Service Group UnitAscension Providence Rochester Hospital Registered Nurse UnitAscension Providence Rochester Hospital Radiology Technologist UnitAscension Providence Rochester Hospital Medical Lab Technologist Unit

I, the undersigned employee, of my own free will and accord hereby authorize and direct the Medical Center to deduct each month from my earnings the amount owed by me for membership dues to RN Staff Council, Office and Professional Employees International Union, Local No. 40 (hereinafter referred to as the “Union”), irrespective of my current or future membership in the Union, and to transmit such amount to the Union each month. As of the date of this authorization, 1.75 times hourly base pay plus yearly increases as mandated by the International OPEIU Constitution and By-Laws will be deducted. However, the amount of membership dues may be changed pursuant to the provisions of the By-Laws of the Union, and in that event the Treasurer of the Union shall notify the Medical Center in writing of the amount of the monthly membership dues as so changed and upon receipt of such notification, the Medical Center is hereby authorized to deduct from my earnings the amount of dues so changed.

If for any reason I should become delinquent in the payment of my membership dues to the Union, I hereby further authorize and direct the Medical Center to deduct from subsequent paychecks as defined in accordance with the Collective Bargaining Agreement and By-Laws.

I hereby agree that neither the Medical Center nor the Union shall be under any liability to me for the deduction of dues from my earnings in the manner described and set forth above and that maintaining my continuous good-standing in the Union is my responsibility.

I reserve the right to revoke this authorization by giving a written notice to the Medical Center either during the fifteen (15) days immediately preceding the anniversary of the Date shown below or during the fifteen (15) days immediately preceding the termination date of any Collective Bargaining Agreement between the Medical Center and the Union which is applicable to me as an employee of the Medical Center; and unless or until revoked in the above stated manner, this authorization shall continue in full force and effect.

INITIATION FEE AUTHORIZATION - NEW ORGANIZED UNITS ARE EXEMPT FROM INITIATION FEE

I, the undersigned employee of my own free will and accord hereby authorize and direct said Medical Center to deduct from my earnings accumulated to my credit the sum of forty dollars ($40.00) for payment of my full Initiation Fee in RN Staff Council, Local 40.

When the Medical Center has made such deductions and paid the forty dollars ($40.00) fee to the Union as herein above provided for this authorization shall become null and void and have no further force or effect. I agree that the Medical Center shall be under no liability to me for making such deductions and that the Union shall be under no liability to me for accepting such amount as payment of my full fee hereinabove stated.

Date*

Date

Signature*

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