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.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
Years in this school
*
Check one:
*
FULL TIME: Elementary and High School
PART TIME: Elementary and High School
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.
Format: (000) 000-0000.
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
*
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 request and authorize La Salle Academy, according to the arrangements agreed upon with the Union, to deduct from my salary and to transmit to the Union the dues/agency fee, 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 La Salle Academy of any liability thereof. This authority shall be irrevocable for a period of one year unless revoked by me in writing to La Salle Academy and to the Union during the thirty (30) day period designated by the Union it is By-Laws.
EMPLOYEES SIGNATURE
*
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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