MEMBERSHIP APPLICATION & BENEFICIARY DESIGNATION
2153 Richmond Ave, Suite B-101, Staten Island, NY 10314 Phone: (718) 370-0081 ~ Email: info@fct153.org
Check one:
*
Mr.
Mrs.
Miss
Ms.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Last four digit SSN
[ex:2153]
Personal E-mail
*
example@example.com
Name of School
*
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title:
*
Teacher- Elementary
Special Subject- Elementary
Teacher- High School
Teacher's Aide / Assistant
Years in this school
*
Check one:
*
Full Time
Part time
Which days do you work?
Monday
Tuesday
Wednesday
Thursday
Friday
Half day: Monday - Friday
Please list other schools at which you have been employed and the time period for each school.
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Beneficiary Information
Equitable Basic Life/ AD&D
Beneficiary's Name
*
First Name
Last Name
Relationship to you
*
[spouse, mother, father, son, daughter, etc...]
Last four digit SSN
[ex:2153]
Cell Phone Number
*
Please enter a valid phone number.
Personal E-mail
*
example@example.com
Beneficiary's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you want to add a contingent beneficiary?
Yes
No
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Beneficiary Information
Equitable Basic Life/ AD&D
Beneficiary's Name
First Name
Last Name
Relationship to you
[spouse, mother, father, son, daughter, etc...]
Last four digit SSN
[ex:2153]
Cell Phone Number
Please enter a valid phone number.
Personal E-mail
example@example.com
Beneficiary's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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PLEASE CHECK AUTHORIZATION(S), SIGN AND DATE BELOW.
COMMUNICATION AUTHORIZATION
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I hereby authorize The Federation of Catholic Teachers to send me emails and text messages to the contact information I provided. The Federation of Catholic Teachers may use emails and text messages to communicate Union matters with all bargaining unit employees. I understand that I can opt-out of receiving these communications at any time by replying "STOP" to a text message or clicking the "unsubscribe" link in an email. I acknowledge that standard text messaging rates may apply to messages sent to my mobile phone number. The Federation of Catholic Teachers will take reasonable steps to protect my personal information in accordance with their Privacy Policy.
DEDUCTION AUTHORIZATION
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I hereby designate the Federation of Catholic Teachers as my representative, for the purpose of collective bargaining, and I hereby request and authorize my employer, or any other member school of the Association which subsequently employs me during the period that this authorization form is in effect, and according to the arrangements agreed upon with the Union, to deduct from my salary and to transmit to the Union the dues, as certified by the Union. I hereby waive the right and claim for said monies so deducted and transmitted in accordance with this authorization, and release my employer and any other member school of the Association that subsequently becomes my employer during the period this authorization is in effect of any liability thereof. This authority shall be irrevocable for a period of one year, and shall continue in full force and effect for successive periods of one year unless revoked by me in writing to the member school that is my employer at the time of said revocation and to the Union during the thirty (30) day period designated by the Union in its By-Laws, subject to the provisions of Article XXVI of the Collective Bargaining Agreement.
EMPLOYEES SIGNATURE
*
DATE
/
Month
/
Day
Year
Date
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