Employee Organization Membership Authorization Form

Employee Organization Membership Authorization Form

(PERC FORM 2023-1.101, Incorporated in R. 60CC-1.101, Effective July 1, 2023)
First Name
Middle 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
Home Phone Number
Is a Steward assisting with this form?
Job Classification Title
Date of Employment

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

No dues until after the contract is ratified. At that time you will receive an email asking for ACH or credit card information.
Payment Type
Bank Name
Account Type
Bank Routing Number
Bank Account Number
Credit Card Number
Expiration Date (MM/YY)
CVV Code
Billing Zip Code
By my signature below, I represent that I desire to be a member of the above-named employee organization.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Email
example@example.com
THE STATE OF FLORIDA WANTS YOU TO KNOW THE FOLLOWING:
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:

Select Payment Method

THE STATE OF FLORIDA WANTS YOU TO KNOW THE FOLLOWING: