Wilson County Firefighters Association Membership Forms

Wilson County Firefighters Association LOCAL 4238
Name
Date of Birth

MonthDayYear
Date
Date of Hire

MonthDayYear
Date
Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
ZIP
Gender
Race
Cell Phone
Social Security Number
Rank
Station Assignment
Shift
Email DO NOT USE COUNTY EMAIL
example@example.com
Have you ever been a member of the IAFF? No

YesNo
(If so, Local #)
Employee ID
I,

First NameLast Name
the undersigned:

a. Apply for membership in the International Association of Fire Fighters Local 4238

b. Authorize the union to be my exclusive bargaining agent for wages, hours, and working

C. Authorize bi-monthly dues deduction from my payroll
I wish to join IAFF Local 4238:

ImmediatelyWhen I come off probation on (After Ride Check offs)
Signature of Applicant

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Date

MonthDayYear
Date

Wilson County Firefighters Association LOCAL 4238Wilson County Firefighters Association

Voluntary Life Insurance Enrollment
I wish to purchase voluntary life insurance on myself (in addition to the $10,000 provided by the union):

_ I choose the $20,000 life insurance on myself ($3.42 per pay period)I choose the $50,000 life insurance on myself ($8.55 per pay period)I decline life insurance on myself at this time
I wish to purchase life insurance on my spouse

I choose $10,000 coverage on my spouse ($1.50 per pay period)I choose $25,000 coverage on my spouse ($3.75 per pay period)
Spouses Name
Spouses Social Security Number
Spouses Date of Birth

MonthDayYear
Date
I decline spousal coverage at this time
I choose to purchase life insurance on my child(ren):
Childs Name
Childs SSN
Childs Date of Birth

MonthDayYear
Date
I decline child coverage at this time
Members Signature

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Date

MonthDayYear
Date

Wilson County Firefighters Association LOCAL 4238

Life Insurance Beneficiary Form
Name of Beneficiary
Relationship to the member
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Email Address
example@example.com
Cell Phone
SSN
Date of Birth

MonthDayYear
Date
Share %
Employment Status
CONTINGENT BENEFICIARY DESIGNATION
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to the member
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
SSN
Share %
Signature

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Date

MonthDayYear
Date

Wilson County Firefighters Association LOCAL 4238

Authorization for Payroll Deduction
I, the undersigned, hereby designate IAFF Local 4238 as my duly chosen and authorized representative on matters relating to my employment. I authorize payroll deduction each pay period to provide for union dues and benefits. This authorization may be terminated by written notice 30 days in advance.
Name
Address

Address

Street Address Line 2

CityState / Province

Zip
Station Assignment
Employee ID
Signature

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Date

MonthDayYear
Date
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Wilson County Firefighters Association LOCAL 4238