Full Name
*
First Name
Middle Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone (Optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization name
*
NEPBA Local #
*
Dues Frequency
Weekly
Bi-weekly
Monthly
Amout
*
Select all that apply
*
I hereby certify that the regular dues of New England PBA for the above named member. I acknowledge I may withdraw from the Union only during the month of July of each year and with written notice to the Union and the City/Town.
I hereby certify that the employee listed above wishes to not be a dues paying member of New England PBA and acknowledges any individual need for Union services shall be required to pay an hourly rate which shall be determined by the Executive Committee.
Signature
*
By selecting the "Send" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual and/or handwritten signature on this Agreement. By selecting "Send" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.
Send
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