MEMBERSHIP APPLICATION AND DUES DEDUCTION

NAME (type or print) ________________________________________________________________________________________________________________________________________

LAST
FIRST
MI
APPLICATION FOR MEMBERSHIP
I hereby apply for membership in AFSCME Local 101 and designate AFSCME as my authorized bargaining representative.

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MEMBER SIGNATURE

DATE OF BIRTH

DATE

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DATE OF HIRE

EMPLOYER

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EMPLOYEE ID NUMBER

JOB CLASSIFICATION/TITLE

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HOME ADDRESS

DEPARTMENT/OFF SITE LOCATION

APT NO.

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HOME ADDRESS, CITY, ZIP, AND COUNTY

WORK ADDRESS, CITY AND ZIP

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HOME E-MAIL

WORK EMAIL

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HOME PHONE

WORK PHONE

CELL PHONE

I authorize my employer to deduct from my earnings the monthly dues amount checked below, or its pay period equivalent, to provide for the regular payment of the current membership dues
rate as established by the AFSCME under the Agreement between AFSCME and the above named Employer. Any changes in the amount to be deducted shall be certified by AFSCME and
automatically implemented by my Employer.

Monthly Dues Category

Please check appropriate box:

Full Time Employee

13 to 24 Hrs per week

$40.26
$26.82

25 to 39 Hrs per week

Less than 13 Hrs per week

$39.32
$19.05

Return this application to your union representative or to the Council 57 office at 80 Swan Way, Suite 110, Oakland, CA 94621
Confidential For Office Use Only
____________ Received

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____________ Submitted to Employer

____________ Confirmed on Employer List

VUE________________

Enterprise __________________________

revised 3/26/14