Membership Application

Membership Application

SEIU Healthcare Pennsylvania, 1500 N. 2nd Street, Harrisburg, PA 17102
utm_source
Name

First NameLast Name
Employer
Department / Institution
Chapter Code
NMO
Date Hired

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

HOME ADDRESS

Street Address Line 2

CITYSTATE/ZIP

Postal / 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
Payroll Deduction Authorization
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
Direct Pay Authorization, Public Sector
In the event my employer ceases payroll deductions, I authorize SEIU HCPA to bill my checking or savings account, in accordance with the authorization provided below. SEIU HCPA will notify me of the transition to direct pay at the current mailing address on file with SEIU HCPA prior to initiating the first payment via checking or savings account as authorized below.

I hereby authorize SEIU HCPA to initiate a recurring, automatic electronic funds transfer with my financial institution beginning on the date listed in the transition notice provided to me in order to deduct from my account the sum equal to 1.8% of my pay the day after every payday designated by my employer. The dues amount may change if authorized according to the requirements of the SEIU HCPA Constitution and Bylaws or the Service Employees International Union Constitution and Bylaws. If this happens, I authorize SEIU HCPA to initiate a recurring, automatic funds transfer in the amount of the new dues amount when notified by SEIU HCPA in writing of the new amount and with at least ten (10) days’ notice before the next funds transfer date. In the case of checking and savings accounts, adjusting entries to correct errors are also authorized. I agree that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. This authorization shall remain in effect until I send written notice of my revocation of authorization to SEIU HCPA via U.S. mail.

I acknowledge that failure to pay my dues on a timely basis may affect my membership standing in the union, as set forth in the SEIU Constitution and Bylaws.

Contributions or gifts to SEIU are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.
Direct Deposit Account Information Authorization

To facilitate payment of the dues or other contributions from my bank account, I authorize my employer or its fiscal agent to provide to SEIU HCPA’s designated secure payment processor the information for the bank account (bank account number and routing number) on file with my employer (“Account”) that I have designated to receive the proceeds of my paycheck via direct deposit. If my employer makes direct deposit of my paycheck to a checking account and a savings account, I hereby authorize my employer to provide the designated secure payment processor the information for the checking account and for my dues and/or other contributions to be deducted from this account. I understand that after the designated secure payment processor receives this data, SEIU HCPA will make reasonable efforts to contact me to confirm the accuracy of the Account information provided by my employer at least 10 days in advance of making the first electronic funds transfer from my Account.
Signature

Clear
Direct Deposit Auth Date

MonthDayYear
Date
Help Support Working Families and Healthcare Issues!
Yes! l'll contribute to help pass laws for safe staffing, affordable healthcare, and good jobs for working families. 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 agree with the terms below.
COPE Amount

$10$7$5Other
COPE Name

First NameLast Name
COPE Date

MonthDayYear
Date
Signature

Clear
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.
Should be Empty:

Payroll Deduction Authorization

Direct Pay Authorization, Public Sector

Help Support Working Families and Healthcare Issues!