APPLICATION FOR MEMBERSHIP

Desiring to become a member of Local Union No. 30, chartered by the Office and Professional Employees International Union, affiliated with the AFL-CIO, I hereby make application for admission to membership and authorize said organization to be my exclusive collective bargaining representative.

Name*

First NameMiddle NameLast Name

Social Security Number*

Employee ID

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Personal Email*

example@example.com

Home Phone

Work Phone

Cell Phone*

Gender

MaleFemaleOther

Date of Birth*

Date

Where Employed*

Hire Date

Date

Job Title

Work Hours

Regular Full-Time/Part-TimeOn-Call

For On-Call employees and Temporary employees, the Employer and the Union have agreed to waive mandatory membership and initiation fee and instead require only a permit fee for each shift worked. The permit fee is based upon your hourly rate and is effective on your first day of employment.

By providing your cell phone number, you agree that OPEIU Local 30 may send you automated calls and/or test messages on your cell phone on a periodic basis. OPEIU Local 30 will never charge for alerts but messages and data rates may apply. You can text HELP for more information and STOP to stop receiving messages to (844) 240-4114 at any time.

Call Preference

I agree to receive automated calls and/or messagesI do not wish to receive automated calls and/or messages

Have you been a member of any Union before?

YesNo

If yes, what Union?

It is understood that upon acceptance of this application, I hereby subscribe to the following obligation: I pledge my honor to faithfully comply with the Constitution Laws and all amendments thereto of Office & Professional Employees International Union Local 30 and of the International Union. I further promise not to divulge or make public any of the private proccedings of this Union to faithfully perform all the duties assigned to me to the best of my ability and skill to so conduct myself at all times as not to bring reproach upon my Union and at all times to bear true and faithful allegiance to the Office and Professional Employees International Union of the American Federation of Labor and Congress of Industrial Organizations.

Date*

Date

Signature of Applicant*

VOLUNTARY DEDUCTIONS FOR THE J.B. MOSS VOICE OF THE ELECTORATE (VOTE) FUND

I hereby assign to the J.B. Moss Voice of the Electorate (VOTE) Fund from any wages earned or to be earned by me as your employee $1.00 per pay period, unless I specify a different amount per pay period in the following space below

Enter amount if different than $1.00 a pay period

I also understand that the $1.00 per pay period, amount above is only a suggestion and that I am free to change the amount or to refuse to contribute to the J.B. Moss VOTE Fund, without being disadvantaged. I authorize and direct you to deduct such amount and to remit same to the J.B. Moss VOTE Fund monthly, in such manner as agreed upon between the Employer and the Union, at any time while this authorization is in effect. This authorization for deductions which are to be forwarded to the J.B. Moss VOTE Fund is signed voluntarily, and with the understanding that my contributions will be used for contributions and expenditures in connection with political election campaign. This authorization of deduction of contributions to the J.B. Moss VOTE Fund may be revoked by me at any time by written notice to both the Employer and the Union.

Signature

Print Name

Date

Name of Employer*

Date

I hereby assign to OPEIU, Local 30 from any wages earned or to be earned by me as your employee such sums as the said Local Union may certify as due and owing from me as membership dues or nonmember fees to the Union in such sums as may be established from time to time by said Local Union. I authorize and direct you to deduct such amounts from my pay and to remit same to the Union at such times and in such manner as may be determined by the Union at any time while this authorization is in effect. This assignment, authorization, and direction shall be effective from the date of my signature below, or until the termination of the collective agreement between the Employer and the Union which is in force at the time of the execution of this authorization, whichever occurs sooner; and I agree and direct that this assignment, authorization and direction shall be automatically renewed, for each succeeding applicable collective agreement between the Employer and the Union, whichever shall be shorter, unless written notice from me is received by both the Employer and the Union by certified U.S. mail. This authorization for check-off of dues, fees, and other monies due and owing to the Union is made voluntarily and pursuant to the provisions of Section 302 (c) of the Labor Management Act of 1947.

Signature of Employee*

Print Name

Date*

Date

(Except as prohibited or modified by state law, this authorization is applicable in all states)

APPLICATION FOR MEMBERSHIP

AUTHORIZATION FOR MY EMPLOYER