Indian River County PERC Application Form

Indian River County PERC Application Form

(PERC FORM 2023-1.101, Incorporated in R. 60CC-1.101, Effective July 1, 2023)
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
Date
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Is a Steward assisting with this form?

YESNO
If YES, enter Steward name. (first initial, last name)
CLASS TITLE
DEPARTMENT / JOB CLASS DESCRIPTION*
CLASS CODE
Date of Employement

MonthDayYear
Date
Rate of Pay*
Department
Select Payment Method

I hereby agree to remit monthly dues by the following payment method.
Bank Name*
Account Type*

CHECKINGSAVINGS
Monthly Dues
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*

Clear
Date of Signature*
Email*
example@example.com (PERSONAL EMAIL ONLY)
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***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.
Should be Empty:

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

Select Payment Method