Membership Application – SEIU HCPA Private Sector

Membership Application

SEIU Healthcare Pennsylvania, 1500 N. 2nd Street, Harrisburg, PA 17102
Please note: for your convenience, some of your information has been pre-filled on this membership card. Please check this information for accuracy before submitting.
Name*

First NameLast Name
Employer*
Chapter ID
NMO
Job Title
Department/Work Area
Employee ID Number
Date Hired

MonthDayYear
Date
Email*
example@example.com
Cell Phone*
Home Phone*
Address*

Home Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Language Preference
YES! I want to join my fellow employees and become a member of SEIU Healthcare Pennsylvania (SEIU HCPA).

I request and accept membership in SEIU HCPA and I agree to abide by the SEIU HCPA constitution on and by-laws. I authorize SEIU HCPA to act as my exclusive representative in collective bargaining over wages, benefits and other terms and conditions of employment with my employer.
Signature*

Clear
Date

MonthDayYear
Date
I recognize the need for a strong union and believe everyone represented by our union should pay their fair share to support its activities. I hereby request and authorize my employer or its successor to deduct from my earnings and to pay to SEIU HCPA an amount equal to the regular monthly dues and initiation fees uniformly applicable to members of SEIU HCPA, regardless if I am or remain a member of the Union. This authorization shall remain in effect unless I revoke it by sending written notice via U.S. mail to SEIU HCPA during the period of thirty (30) days before (1) the annual anniversary date of this authorization or (2) the termination date of the applicable contract between my employer and SEIU HCPA. This authorization shall automatically renew from year to year even if I have resigned my membership in SEIU HCPA unless I revoke it in writing during one of the revocation periods. I recognize that my agreement authorizing payroll deduction and its automatic renewal is voluntary and not a condition of employment.

Contributions or gifts to SEIU are not tax deductible as charitable contributions.

This card supersedes any prior payroll deduction authorization I signed.
Signature*

Clear
Yes! I'll contribute to help pass laws for safe staffing, affordable healthcare, and good jobs for working families. I hereby authorize my employer to withhold the indicated amount bi-weekly to forward to SEIU HCPA as a contribution to SEIU Committee on Political Education (SEIU COPE). My signature shows that I agree with the terms below.
COPE Amount

$10$7$5Other
COPE Amount Sync
COPE Amount Other for PDF
Signature

Clear
COPE Name

First NameLast Name
COPE Date

MonthDayYear
Date
This authorization is made voluntarily based on my specific understanding that: 1) I am not required to sign this form or make voluntary contributions to SEIU COPE as a condition of my employment or membership in the union; 2) I may refuse to contribute without reprisal; 3) Under law, only union members and executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to COPE; 4) The contribution amounts on this form are merely suggestions, and I may contribute more or less by this or other means without fear of favor or disadvantage from SEIU or my employer; 5) SEIU COPE uses the money it receives for political purposes – including, but not limited to, making contributions to and expenditures on behalf of candidates for federal, state, and local offices – and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU.

Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.
*By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.
Source
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