ITPEU Membership Application

I,the undersigned, do hereby apply for membership in the Industrial, Technical & Professional Employees Union, OPEIU Local 4873, AFL-CIO ("Union") and designate the Union to act as sole collective bargaining agent on all matters affecting my wages, hours and working conditions, with (name of Company, and/or its successor I further consent to the use of this application as evidence that the Union represents a majority of employees in any bargaining unit. I am applying for membership of my own free will and without inducement, insistence or coercion by any officer or authorized representative of the Union.
Date*

MonthDayYear
Company*
SSN (Last 4)*
Name*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Telephone*
Birthdate*

MonthDayYear
Date
Company*
Hire Date*

MonthDayYear
Date
Shop Steward / Witness
ITPEU Branch Office
Worksite / Workplace
PLEASE COMPLETE ENTIRE APPLICATION

To (Company) and/or its successors:

I hereby authorize you to deduct from my wages each pay period commencing
Company*
Date*

MonthDayYear
Date
a proportionate amount of my monthly membership dues or nonmember fees as designated by Industrial, Technical & Professional Employees Union, OPEIU Local 4873, AFL-CIO (ITPEU), while I am an employee of the Company or its lawful successor. The aforesaid membership dues or nonmember fees shall be remitted promptly by you to a designated official or employee of ITPEU. This authorization shall be irrevocable, regardless of whether I remain a member of ITPEU, for a period of one (1) year from the date appearing above or until the termination date of the current collective bargaining agreement between the company, or its lawful successor, and ITPEU, whichever occurs sooner. I further direct you to maintain this authorization in effect, regardless of whether I remain a member of ITPEU, after the expiration of the shorter of the periods specified above for further successive periods of one (1) year provided there is then in effect a collective bargaining agreement between the Company, or its lawful successor, and the ITPEU providing for check off of Union dues and/or nonmember fees, or there is a check off provision in effect by operation of law.

This authorization may only be revoked during the 15 day period following the expiration of any such year or during the 15 days following the termination date of the collective bargaining agreement between the Company, or its successor, and the ITPEU covering my employment if such date shall occur within one ofthe aforesaid annual periods. I further agree that this authorization may only be revoked by written notice signed by me and received by the Company and the ITPEU during any such 15 day period. Any such revocation shall become effective immediately upon receipt by the Company and the ITPEU, and no dues shall be deducted from my wages following such receipt.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: