Cope Contribution

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Database ID

Name*

First Last

Email*

Please provide a personal e-mail address not provided by your employer

Employee ID Number*

Employer*

Birthdate*

Cell Phone*

Allow Text Messaging

Allow Text Messaging

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 721721 to stop receiving messages. Text HELP to 721721 for more information.

Cope Amount per Pay Period*

Work Location*

Workplace Details*

Ward/Floor/Unit/Station

Race/Ethnicity

Gender

Male
Female
Nonbinary

Are You Registered to Vote?

Yes
No

Political Party

Do you belong to any community organizations?

Yes

Which Organizations?

Cope Contribution Agreement

I understand that: 1) I am not required to sign this form or make COPE contributions as a condition of my employment by my employer or membership in the union; 2) I may refuse to contribute without any reprisal; 3) Only union members and executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to SEIU Local 721 COPE; 4) The amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer, 5) SEIU Local 721 COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections. Contributions to SEIU Local 721 COPE are not deductible for federal income tax purposes. This authorization shall remain in effect until revoked in writing by me. I authorize my employer to deduct my contribution every month from my paycheck and transfer the funds to SEIU Local 721 COPE. My signature shows that I have reviewed and agree with the terms on this form.

Consent*

I agree to the Cope Contribution Agreement.*

Signature*

I understand this is a legal representation of my signature

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URL Referer

Together we can build a stronger economy and win good middle class jobs. Each of us can play a part.

Cope Contribution Agreement