Clinics Union Authorization Card

Clinics Digital Authorization Card

I support working alongside my co-workers to create a stronger voice in decisions affecting our workplace, families, and future. My signature authorizes the Service Employees International Union (SEIU) Local 721 to serve as my exclusive representative for purposes of engaging in collective bargaining with my employer regarding my hours, wages, and terms and conditions of employment. I understand this authorization card can be used by SEIU Local 721 to establish support among employees for a NLRB election and/or to obtain voluntary recognition as my exclusive collective bargaining representative.
Employee Information
First Name*
Middle Initial
Last Name*
Job Title*
Employer/Clinic*
Department
If you work in a specific department please list it. If not please leave it blank.
Cell Phone
Email Address*
By providing my cellular telephone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. To stop receiving messages, text STOP to 721721. Text HELP to 721721 for more information.
By providing my cellular telephone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. To stop receiving messages, text STOP to 721721. Text HELP to 721721 for more information.
Home Address*
Street Address City Zip Code
Signature
YES, I UNDERSTAND AND AGREE TO THE TERMS ABOVE.*
Please check the box above to confirm
Electronic Signature*
BY CLICKING SUBMIT, YOU ACCEPT THAT YOUR PRINTED NAME, IP ADDRESS AND THE DATE AND TIME WILL BE USED AS YOUR DIGITAL SIGNATURE FOR THE PURPOSES OF THIS FORM.
Today's Date*

Clinics Union Authorization Card

Clinics Digital Authorization Card

Employee Information

Signature