• NAME OF EMPLOYEE ORGANIZATION: Government Supervisors Association of Florida-OPEIU, Local 100, AFL-CIO
• PERC REGISTRATION NUMBER: 1986-213
• DATE OF LAST ORDER GRANTING REGISTRATION (mo/day/year): 03/08/2025
• INITIATION FEE: Zero
• DUES (indicate the applicable amount): MONTHLY: $ 45.00

OFFICER/EMPLOYEE COMPENSATION: List the salaries, allowances, and other direct or indirect disbursements, exceeding $10,000.00 in the aggregate, paid by the employee organization and any affiliates to the five highest compensated individuals, as reported on the last PERC registration or renewal application. If fewer than five individuals are reported, indicate "N/A" on any remaining blank lines.

By my signature below, I represent that I desire to be a member of the above-named employee organization.

***THE STATE OF FLORIDA REQUIRES YOU TO HAVE NOTICE OF THE FOLLOWING INFORMATION***

NOTICE

The State of Florida is a right-to-work state. Membership or non-membership in a labor union is not required as a condition of employment, and union membership and payment of union dues and assessments are voluntary. Each person has the right to join and pay dues to a labor union or to refrain from joining and paying dues to a labor union. No employee may be discriminated against in any manner for joining and financially supporting a labor union or for refusing to join or financially support a labor union.

INSTRUCTIONS FOR COMPLETING FORM 2023-1.101

INTRODUCTION: Every line must be completed. The employee organization, public employee, or another person assisting the employee may complete any portion of the form with accurate information as reflected in the organization's most recent registration or renewal application filed with the Public Employees Relations Commission (PERC) The employee must personally sign and date the form after all other blanks are completed. The completed form must be delivered to the employee organization identified on the form. Exemptions from this form are provided in section 447.301(1b)6., Florida Statutes, as amended by chapter 2023-35, section 1, Laws of Florida.

Name of Employee Organization: The official name of the employee organization as it is registered with the Public Employees Relations Commission.

PERC Registration Number: The registration number (also referred to as "case number") assigned to the employee organization by the Public Employees Relations Commission upon the granting of a registration application.

Date of Last Order Granting Registration: The date of the Public Employees Relations Commission's most recent order granting or renewing the registration of the employee organization.

Initiation Fee: The actual amount of any initiation fee as it is required to be paid, as of the date the public employee signs the form. If none, state zero.

Dues: In the appropriate blank, provide the monthly, bi-weekly, weekly, or annual dues, as of the date the public employee signs the form.

Officer/Employee Compensation: This information must be the same as what is reported in the employee organization's most recent annual registration or renewal application filed with the Public Employees Relations Commission. Only provide information on the five highest compensated individuals listed on that application, if any. Insert "N/A" on any empty line if fewer than five individuals are listed.

• Allowances: Regular compensation to an officer or employee of the organization to cover expenses related to service to the organization.
• Other direct or indirect disbursements: All other amounts paid to the organization's officer or employee, including reimbursed expenses, from the organization and any other employee organization affiliated with it, or with which it is affiliated, or which is affiliated with the same national or international employee organization.

PART B - EMPLOYEE INFORMATION:

Name of Employee: The name of the "public employee," as defined in section 447.203(3), Florida Statutes, who desires to be a member of an employee organization that is either (1) certified to represent a bargaining unit that includes the public employee, or (2) seeking to become a certified bargaining agent for a prospective bargaining unit that includes the public employee.

Name of Public Employer: The public employer is one of the following, depending upon the type of public employment:

Name of Agency: The state agency, or the political subdivision's agency, department, or other sub- unit that actually employs the public employee, if different from the listed "public employer." If the agency is the same as the "public employer," check the box to indicate this.

Class Title: The classification applicable to the employee used in the bargaining unit definition in the most recent Certification Order of the Public Employees Relations Commission, if any. If there is not an active bargaining unit certification applicable to the employee, the employee should list the class title assigned by the employer.

Class Code: The code, if any, assigned by the employer to the employee's classification. If there is no class code, check the box next to "Not Applicable."

PERC Form 2023-1.101, Effective July 1, 2023, Incorporated in R. 60CC-1.101