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

Worksite

Work Phone

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

I hereby apply for membership in Local

Oregon AFSCME Council 75 and I agree to abide by its Constitution and Bylaws. By this application, 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. Effective immediately, 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. I further authorize my Employer to remit such amount monthly to Oregon AFSCME Council 75. This voluntary authorization and assignment is revocable by providing the Union written notice of revocation not less than ten (10) days and not more than twenty (20) days before the yearly anniversary of the signing of this membership card, unless an applicable collective bargaining agreement imposes other limitations. 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.

I have read and agree to the Union Membership Card & Payroll Deduction Authorization.

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.

Authorization for Representation - Dual Language (Local)