State Employees Membership Card

YES! I want to join our union so we can win respect, better wages and a voice on the job.

First Name *

M.I.

Last Name *

Home Address *

Address 1 *

Address 2

City *

State *

ZIP code *

Personal Email Address *

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 by emailing the Union at [email protected] or calling the Union at 609.586.9093.

Home Phone

Social Security Number * Last four digits only (XXX-XX-1234)

Local Number

Employer *

Occupation/Job Title *

Classification

Worksite

Authorization

I hereby apply for membership in AFSCME New Jersey, Council 63 agree to abide by its Constitution and ByLaws, and designate that organization, its subordinate bodies and its successors or assigns (hereafter, “AFSCME New Jersey Council 63” or 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.

Effective immediately, I hereby voluntarily authorize and direct my Employer to deduct from my pay each pay period the amount of dues certified by AFSCME New Jersey Council 63, and as they may be adjusted periodically by the Union, and to authorize my Employer to remit such amount monthly to AFSCME New Jersey Council 63. The monthly amount shall be sent to AFSCME New Jersey Council 63 or another subordinate body as directed by the Union.

This voluntary authorization and assignment shall remain in effect, regardless of whether I am or remain a member of the Union, unless I revoke it by providing written notice to the employer’s payroll clerk during the ten (10) days following each anniversary date of employment. Within five (5) days of receipt of my notice of revocation of authorization for payroll deduction of dues, the public employer shall provide notice to the Union of my revocation of such authorization. I understand that my notice of revocation of authorization for the payroll deduction of dues shall be effective on the thirtieth (30th) day after the anniversary date of my employment. This card supersedes any prior check-off authorization card I signed.

I recognize that my authorization of dues deductions is voluntary and not a condition of my employment.

Payments to AFSCME New Jersey Council 63 are not deductible as charitable donations for federal income tax purposes. However, state law may extend favored tax treatment.

Signature