AFSCME Local 4041 Conversion Card

Yes! I am AFSCME Strong. I want a strong voice at work and in my community.

First Name *

Middle Initial

Last Name *

Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Personal Email Address *

Cell Phone † † By providing my cell phone number and email address, I understand that the Union and its affiliates may use automated email, calling technologies, and/or text message me on my cell phone on a periodic basis. The Union will not charge for text message alerts; carrier message and data rates may apply to such texts.

Employer *

EIN

Date of Hire

Month

Day

Year

Department

Worksite *

Job Classification

Authorization

I hereby apply for membership in AFSCME, Local 4041, and its successor or assign (hereafter the “Union”), and I agree to abide by its Constitution and Bylaws. I authorize the Union to act as my exclusive bargaining representative for purposes of collective bargaining with respect to wages, hours and other terms and conditions of employment with my Employer. This card may be used to establish or obtain recognition of the Union with my Employer, with or without an election. 

Upon being covered by an agreement with my Employer, I hereby voluntarily authorize and direct my Employer to deduct from my pay each pay period, regardless of whether I am or remain a member of the Union, the amount of dues certified by the Union, and as they may be adjusted periodically by the Union, and to authorize my Employer to remit such amount monthly to the Union. This voluntary authorization and assignment shall be irrevocable, regardless of whether I am or remain a member of the Union, for a period of one year from the date of execution, and for year to year thereafter unless I give the Union written notice of revocation not less than ten (10) days and not more than twenty (20) days before the anniversary date of this authorization. This card supersedes any prior check-off authorization card I signed.

I recognize that my authorization of dues deductions, and the continuation of such authorization from one year to the next, is voluntary and not a condition of my employment. Payment to the Union are not deductible as charitable donations for federal income tax purposes. However, state law may extend favored tax treatment.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.

AFSCME Members Win Big!

AFSCME Local 4041 Conversion Card

Yes! I am AFSCME Strong. I want a strong voice at work and in my community.

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