Application for Membership Local 947 (Associate)

3 Main Street, Kings Park, NY 11754

Tel: 631-670-5660 Fax: 631-670-5662
APPLICATION FOR MEMBERSHIP

Associate
I apply for membership in Local 947 and designate this Union to represent me for collective bargaining with my employer.
Date

MonthDayYear
Date
Signature

Clear
I direct my employer to deduct from my wages and to pay Local 947 dues and initiation fees in said Union as may be established by the Union and become due to it from me during the effective period of this authorization. This authorization may be revoked by me by written notice signed by me as of any anniversary date hereof or termination date of any collective bargainig agreement covering my employment, whichever occors sooner. This authorization shall automatically renew unless written revocation is submitted.
Date

MonthDayYear
Date
Signature

Clear
EMPLOYEE INFORMATION
Name

Last NameFirst NameMiddle Int
SEX:

MF
DATE OF BIRTH

MonthDayYear
Date
Marital Status

MarriedDivorcedSingleWidowedSeparated
Your Social Security Number *
xxx/xx/xxxx
Home Address

Street Address

Apt. No.

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Email
example@example.com
Current Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone

Area CodePhone Number
Date Of Hire

MonthDayYear
Date
LIFE INSURANCE

Local 947 Health & Welfare Fund

BENEFICIARY NAME

Pursuant to the by laws of Local 947 USWU, I hereby apply for Associate Membership. I understand that Associate Members are individuals who are not part of a bargaining unit for which the local is the exclusive bargainig agent but are part of a group or is an individual which has been approved by the Executive Board as being eligible for Associate Membership. I understand Associate Members are allowed to attend membership meeings, but do not have voting rights or the right to nominate or run for office. I further understand that as an Associate Member I will be permitted to participate, at my complete discretion and at my own cost, in any benefit programs offered to Local 947 Associate Members and that my monthly Local 947 membership fee of $26.50 per month may be included in the cost of that benefit program. I further understand that should I be approved as an Associate Member, I can revoke my membership at any time.
Indicate acceptance by checking below

I acceptI do not accept
Signature
Date

MonthDayYear
Date
Please verify that you are human*
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EMPLOYEE INFORMATION