Membership–At- Large / Council of Retirees Application

Membership-at-Large is offered to an HPAE member who has left the bargaining unit represented by a local. Membership in the Council of Retirees is offered to HPAE members who have retired from a bargaining unit represented by a local. This application must be completed and, if accepted, you shall retain membership standing in your local. Dues are $40 per year.

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First Name *

Middle Name

Last Name *

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Billing Country *

Billing Address *

Billing City *

Billing State *

Billing Zip Code *

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Personal E-mail *

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Phone(Home) :

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Mobile:

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Former Employer - Local Number: *

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Current place of employment:

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Please select: *

Membership-at-large

Council of Retirees

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Select your membership category

Dues Amount

$0.00

Total * draft

Payment Methods

credit/debit card

bank draft

account type

Credit Card Types

Visa

Master Card

Discover

American Express

Name on Card

Card Number

Card Expiration Date

Month

Year

Card Security Code

account type

Bank Account Types

checking

saving

Bank Name

Routing Number

Account Number

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Authorize

I agree to be a member of HPAE Council of Retirees- MAL Local 08071R, authorize HPAE Council of Retirees- MAL Local 08071R to represent me to the fullest extent of the law, and accept the terms of the agreement below.

Council of Retirees - Local 8071-R By providing the information on this form, I authorize the Health Professionals and Allied Employees (HPAE) Council of Retirees - Local 8071R and the American Federation of Teachers (AFT) to deduct dues for membership per the above information and in accordance with the HPAE Council of Retirees - Local 8071R constitution, the HPAE constitution, and the AFT constitution. Member-at-Large - By providing the information on this form, I authorize the Health Professionals and Allied Employees (HPAE) and the American Federation of Teachers (AFT) to deduct dues for membership per the above information and in accordance with the HPAE constitution and the AFT constitution. Dues payments are not deductible as charitable contributions for federal income tax purposes, but a portion thereof may be deductible as a miscellaneous itemized deduction. The dues amount may change if authorized according to the requirements of the local, state or national constitutions. If this happens, I authorize my bank or credit card to adjust my payment when notified by the HPAE Council of Retirees - Local 8071R. I agree this authorization remains in effect until terminated by me in writing.

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$0.00