Authorization for Representation

I, the undersigned hereby designate AFSCME as my duly chosen exclusive representative for the purpose of collective bargaining with my employer concerning my wages, hours, and other conditions of employment. I understand that my signature on this card may be used to obtain certification of AFSCME as my exclusive bargaining representation without an election. This is not a membership application and does not authorize deduction of dues.

First Name

Middle Initial

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Employer

Employee ID No.

Job Class/Title

Work Phone

Worksite

Shift

Hire Date

Home Email

Home Phone

Cell Phone †

† By providing my cell phone number I consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. My carrier’s rates may apply. I may modify my preferences at https://www.afscme.org/tcpa.

Union Membership Card & Payroll Deduction Authorization

YES! I authorize Oregon AFSCME Council 75 and its successor or assign 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. I choose to be a Union member. I support advocating for quality service and good jobs. I understand that by becoming a union member I will make our union stronger to protect jobs and the services we provide!

Effective after the ratification of my first contract, 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 Oregon AFSCME Council 75, and as they may be adjusted periodically by the Union. Oregon AFSCME Council 75 is authorized to submit this authorization to any Employer under contract with it in the event I should change employment or to the same Employer if I return to work after a hiatus from active employment. I further authorize my Employer to remit such amount monthly to Oregon AFSCME Council 75. This voluntary authorization and assignment is irrevocable for the period of one year from the date I sign this authorization or until the termination of the applicable collective agreement between the Union and my Employer, whichever occurs sooner, and I agree and direct that this authorization shall be automatically renewed, and shall be irrevocable for successive one-year periods or for the period of each succeeding applicable collective agreement, whichever shall be shorter. To revoke this authorization, I agree that I will give written, signed notice to the Union and to my Employer not more than 20 days and not less than 10 days prior to (i) the end of the initial or any successive one-year period, or (ii) the termination of my initial or any successive collective agreement, whichever occurs sooner. The applicable collective bargaining agreement (if there is one) is available for review upon request. 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. Payments to the Union are not deductible as charitable donations for federal income tax purposes. However, they may be tax deductible as ordinary and necessary business expenses.

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.