OPEIU Local 12 MEMBERSHIP APPLICATION

I, the undersigned, hereby make application for admission to membership in the Office and Professional Employees International Union, AFL-CIO, Local 12 serve as my chosen and authorized collective bargaining representative on matters relating to wages, benefits, hours, and other conditions of my employment.

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Email *

Employer *

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Are you FT, PT, OC # of hours work/week *

Birthdate (for identification purposes): month date year

Date

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Hourly Rate of Pay *

*Cellphone number for texting

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Personal Email

Alternate Phone

*By providing my cell phone number and clicking "I consent", I authorize OPEIU Local 12 and its affiliates to use automated calling technologies and/or text message me on my cell phone on a periodic basis. Carrier message and data rates may apply to such texts.

I authorize and direct my employer to deduct from my pay and to remit to OPEIU 12 membership dues and initiation fees in such sums as established by the Union Constitution and Bylaws. This authorization shall be irrevocable for one year after it is first executed or until termination of the collective bargaining agreement between my employer and the Union whichever occurs sooner. Revocation shall become effective when written notice is given by me to my employer and to the Union.

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Contributions or gifts to Local 12 are not tax deductible as charitable contributions.

OPTIONAL – CONTRIBUTIONS TO THE J.B. MOSS VOTE FUND

B. I hereby assign to the J.B. Moss Voice of the Electorate (VOTE) Fund from any wages earned or to be earned by me as your employee, $1.00 per pay period, unless I specify a different amount per pay period in the following space: . I also understand that the $1.00 per pay period amount above is only a suggestion and that I am free to change the amount, or to refuse to contribute to the J.B. Moss VOTE Fund, without being disadvantaged. I authorize and direct you to deduct such amount and to remit same to the J.B. Moss VOTE Fund monthly, in such manner as agreed upon between the Employer and the Union, at any time while this authorization is in effect. This authorization for deductions which are to be forwarded to the J.B. Moss Vote Fund is signed voluntarily, and with the understanding that my contribution will be used for contributions and expenditures in connection with political election campaigns. This authorization of deduction of contributions to the J.B. Moss Vote Fund may be revoked by me at any time by written notice to both the Employer and the Union

Please type any additional amount over 1.00 per pay check you wish to contribute to contribute here.

Signature of Employee

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For Local 12 office use only

Entered into internal database Employer copy sent to employer Initiation fee received Filed Other/comments