AFSCME Local 1004 Membership Card

YES! 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, public service employees, and the services we provide!

First Name *

Middle Initial

Last Name *

Birthdate *

Month

Day

Year

Work Information

Employer *

Employee Number

Occupation/Job Title *

Work Phone

Worksite *

Shift

Personal/Contact Information

Personal Email Address *

Cell Phone † * † By providing my cell phone number, I understand that AFSCME and its affiliates may use automated calling technologies and/or text message me on my cell phone on a periodic basis. Carrier message and data rates may apply to such texts.

Home Phone *

Authorization

I hereby apply for membership in AFSCME Local 1004 and I agree to abide by its Constitution and Bylaws. By this application, I authorize AFSCME Local 1004 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 AFSCME Local 1004, and as they may be adjusted periodically by the Union. I further authorize my Employer to remit such amount monthly to AFSCME Local 1004. This voluntary authorization and assignment is revocable by providing the Union and my Employer 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.

Printed Name *

Date *

Month

Day

Year

WE MAKE UTAH HAPPEN!

AFSCME Local 1004 Member Card

AFSCME Local 1004 Membership Card

YES! 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, public service employees, and the services we provide!

Work Information

Personal/Contact Information