For Payroll deduction purposes, AFSCME Local 4041 must have an original signature 
on the completed card, we cannot accept an emailed or faxed copy.

AFSCME MEMBERSHIP APPLICATION
(Please print clearly)

Name: ______________________________________SS#______--_____--________

Residential Address: _____________________________________________________

City: __________________________________ State: _________ Zip: _____________

Mailing Address: ________________________________________________________

City: _________________________________ State: _________ Zip: ______________

Home Email Address: ____________________@____________  DOB ____/____/____ 

Home Phone: ______________________Work Phone: ________________________

 Date of Hire with State:____/____/____ Employing Agency: _______________________

    Department: ___________________________ Classification: _____________________

Registered Voter:    Y    N           Assembly District: ________ Senate District: _________

AFSCME Chapter: __________________ Recruited By: _________________________

Date: _____/_____/______ Signature: _______________________________________

I understand that this application is for membership in the AFSCME Local 4041, and authorizes AFSCME Local 4041 to represent me in matters pertaining to my employment with the State of Nevada.  This includes membership in the Political Information Committee, Inc. I HEREBY AUTHORIZE  my employer to deduct from my salary the membership dues and benefit program payment in effect at this time or as modified in the future. Membership dues are 1% of base compensation pay before taxes, each pay period; probationary employees dues are 1/2%.
 This authorization will remain in effect as outlined in NAC 281.260

Office Use Only:  Received: _____/_____/_____ Probation Period: _____/_____/_____Start Date: _____/_____/_____