UWHC-CWA Membership Application

UWHC-CWA Membership Application

Communications Workers of America Local 6154
Name*

First NameLast Name
Employee ID*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Phone
Please enter a valid phone number.
Personal Email*
example@example.com
Employer*
Job Title*
Work Location*
Monthly Membership Dues (based on annual income)*

$10/month (relief/part-time)$15/month (< $39,000)$23/month ($40,000-$49,999)$27/month ($50,000-$59,999)$35/month ($60,000-$74,999)$50/month ($75,000-$99,999)$60/month (> $100,000)
Dues payment method:*

Monthly payroll deduction from my paycheckMonthly bank draft from my bank account
Committee on Political Education/Political Action Fund (COPE-PAF): Contribute to UWHC-CWA's political action fund to increase our influence in national, state, and local politics. As public employees it's critical that we be able to support elected officials who support us on our issues. Unfortunately, only U.S. citizens can contribute per federal law. This contribution is in addition to your monthly membership dues, which cannot be used to support political candidates.

None$5.00 per month$10.00 per month$15.00 per month$20.00 per month
COPE-PAF contributions must be via bank draft and not payroll deduction. To learn more about the CWA Committee on Political Education/Political Action Fund, click here.
Total monthly calculation
Total monthly calculation ($)
COPE Total
Bank Draft Total
Dues Total

Optional question: what motivated you to join the union?
Optional question: what's your preferred method of communication?

Phone callTextEmail
I hereby, voluntarily, authorize and direct the Communications Workers of America Local 6154, to deduct from my paycheck/bank account each month for the amount I have indicated above. In order to process your application, you must include your account numbers. I understand that I may revoke this authorization at any time by written notice to harriscenterunion@gmail.com.*

Check to authorize
I understand that I am responsible for informing the union (CWA Local 6154) when I leave my work position so that my membership can be ended. I may revoke my membership by written notice to harriscenterunion@gmail.com.*

I understand
Signature*

Clear
Should be Empty:

Monthly Bank Draft Information
Bank Account Type
Routing Number	Account Number
Your Name On Account (22 character maximum. If your name exceed this, enter only the first 22 characters.)	Bank Name