Membership Application

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Employer Name*

Employee ID Number*

First Name*

Middle Initial

Last Name*

Birthdate

Gender

Preferred Language

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Extension

Personal Email*

Work Email

Job Title

Hire Date

Annual Salary

Work Status

Department Name

Shift

Facility Name

Facility Address

Street Address Address Line 2 City State Zip Code

Division(if applicable)

Unit/Floor/Room/Other

Membership Agreement

Yes, I want to join my fellow employees and become a member of SEIU Local 721! I request and voluntarily accept membership in SEIU Local 721 and its successors or assigns (collectively “Local 721”). This means I will receive the benefits and abide by the obligations of membership set forth in both Local 721’s and the Service Employees International Union’s Constitutions and Bylaws. I authorize Local 721 to act as my representative in collective bargaining over wages, benefits, and other terms/conditions of employment with my employer, and as my exclusive representative where authorized by law. My membership will be continuous, unless I resign by providing notice to Local 721 via U.S. mail (or other method if permitted by Local 721’s policies). I know that union membership is voluntary and not a condition of employment, and that I can decline to join without reprisal.

I agree to the Membership Agreement

Signature*

I understand this is a legal representation of my signature

Dues Deduction Agreement

I request and voluntarily authorize my employer to deduct from my earnings and to pay to Local 721 and its successors and assigns (collectively “Local 721”) an amount equal to Local 721’s regular dues. This dues deduction authorization shall remain in effect unless I revoke it by providing notice to Local 721 via U.S. mail (or other method if permitted by Local 721’s policies) within 15 days before or after (1) the annual anniversary date of this agreement or (2) the termination of the applicable collective bargaining agreement between my employer and union (my “window periods”). This dues deduction authorization will renew automatically from year to year even if I have resigned my membership, unless I revoke it during a window period and as required by Local 721’s policies. This dues authorization is voluntary and is not a condition of my employment, and I can decline to agree to it without reprisal. I understand that all members benefit from everyone’s commitments because they help to build a strong union that is able to plan for the future. This dues authorization will remain effective if my employment with the Employer ends and I am later re-employed by the Employer. It is my responsibility as a member to notify the Union if I believe my deductions are incorrect or if I am no longer in a bargaining unit represented by SEIU Local 721.

I agree to the Dues Deduction Agreement

Signature*

I understand this is a legal representation of my signature

Yes, By providing my phone 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. Text STOP to [any text from us or 721721 to stop receiving messages. Text HELP to 721721 for more information.

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Organizer

Co-Worker

Organizer

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