City of Lauderhill PERC Application Form

City of Lauderhill PERC Application Form

(PERC Form 1.101 Effective 10/26, Incorporated in R. 60CC-1.101, F.A.C)
I consent to electronic records and signatures.
INITIATION FEE : $ 0

Monthly Dues are calculated by multiplying the hourly rate by 2.25 and rounding to the nearest dollar.
EMPLOYEE INFORMATION ***THE EMPLOYEE MUST PERSONALLY SIGN AND COMPLETE THE DATE OF SIGNATURE
FIRST NAME
LAST NAME
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is a Steward assisting you with this form?
If YES, enter Steward name. (first initial, last name)
CLASS TITLE (Job Title)
CLASS CODE
CLASS CODE
Date of Employment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rate of Pay
Department
Select Payment Method

I hereby agree to remit monthly dues by the following payment method.
Account Type
Monthly Dues
Bank Name
Bank Routing Number
Bank Account Number
By my signature below, I represent that I desire to be a member of the above-named employee organization.
Signature of Employee
Date of Signature
Email
example@example.com
THE STATE OF FLORIDA REQUIRES YOU TO HAVE NOTICE OF THE FOLLOWING INFORMATION

As a public employee in the State of Florida, membership or nonmembership in a labor union is not required as a condition of employment. Union membership and payment of membership dues are voluntary. A public employee’s right to join and pay membership dues to a labor union or to refrain from joining and paying membership dues to a labor union is protected by both Florida’s right-to-work law and the First Amendment of the United States Constitution. A public employer may not discriminate against a public employee for joining and financially supporting, or refusing to join and financially support, a labor union.
Should be Empty:

EMPLOYEE INFORMATION ***THE EMPLOYEE MUST PERSONALLY SIGN AND COMPLETE THE DATE OF SIGNATURE

Select Payment Method