OFNHP Membership Dues Authorization Card

OFNHP Membership Dues Authorization Card
FIRST NAME*
LAST NAME*
MIDDLE NAME
PREFERRED NAME
NAME*

First NameMiddle NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELL PHONE*
HOME PHONE
HOME EMAIL*
example@example.com
EMPLOYER*
DATE of HIRE*

MonthDayYear
Date
WORKSITE*
DEPARTMENT*
JOB TITLE*
Employee Authorization
Through our union, we can achieve together what we can’t do alone–better wages, affordable healthcare, and safer workplaces. Together, we have the power to improve our lives at work, protect our patients, and lift up our community.

Dues Authorization: During my employment, I hereby agree to pay an amount equal to dues as certified by the Union regardless of whether I am or remain a Union member. I also authorize my employer to deduct from my pay each pay period that amount that is equal to dues and to remit such amount monthly to the Union.
Select One*

Full Membership Dues - I choose to have full membership rights, including the right to vote on my contract, select union stewards, elect union officers, and hold office.Non-Member Fees - I choose not to be a union member. I will not have the right to vote on my contract, select union stewards, elect union officers, or hold office.
Revocation Window: This voluntary authorization and assignment shall be irrevocable regardless of whether I am or remain a member of the Union, for a period of one year from the date of authorization, or until the termination date of the collective bargaining agreement between the Union and the Employer, whichever occurs sooner, and shall automatically renew from year to year unless I revoke this authorization by sending written notice by the United States Postal Service to the Union postmarked between August 1 and August 31 or by sending written notice by the United States Postal Service to the Union upon the termination of the collective bargaining agreement.

IRS Disclaimer: Payments to the Union are not deductible as charitable donations for federal income tax purposes. However, they may be tax deductible as ordinary and necessary business expenses.

Telephone Consumer Protection Act Statement: By providing my cell phone number, I understand that the Union and its affiliates may use automated calling technologies and/or text message me on my cell phone on a periodic basis, and that I can unsubscribe from these messages. The Union will never charge for text message alerts; carrier message and data rates may apply to such texts.
PRINT NAME*
EMPLOYEE ID*
SIGNATURE*

Clear
initials constitute a signature
DATE SIGNED*

MonthDayYear
Date
RealFileName
OFNHP / AFT Local 5017 unites over 5000 nurses & health professionals in Oregon & SW Washington.

Phone: (503) 657-9974 • Fax: (503) 657-7456 • email: itsmyunion@ofnhp.org • www.ofnhp.org
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OFNHP Membership Dues Authorization Card

Employee Authorization