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Membership Application NJ Private Sector
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YES, I wish to benefit as a member of Health Professionals & Allied Employees, AFT/AFL-CIO (“HPAE”), and fully participate in its activities. I authorize HPAE, its agents, representatives, and successors, to act for me as a collective bargaining representative in all matters pertaining to rates of pay, wages, hours of employment, or other conditions of employment. When accepted as a member I agree to be bound by the Constitution and Bylaws of HPAE and of the HPAE Local Union that represents me at my workplace.
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First Name
*
Middle Name
Last Name
*
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Mailing Country
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United States of America
Mailing Address
*
Mailing Suite
Mailing City
*
Mailing State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
US Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
Mailing Zip Code
*
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Home Phone
Mobile Phone
Preferred Phones
preferred
preferred
Personal E-mail
*
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Date of birth
Date
E.g., 2024-12-04
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Home Phone
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Mobile Phone
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Personal Email
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Work email
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Work Location
*
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Receive text message- Message and data rates may apply
*
Receive text message- Message and data rates may apply
Yes
No
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Employee ID
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Date of Hire
*
Date
E.g., 2024-12-04
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Job title
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Department
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Shift
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Campus
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Building
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floor-room number
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Are you currently, or have you ever been, an HPAE member at another location?
*
Yes
No
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If yes where?
payroll-deduction
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Select your membership category
Select your membership category
Full Dues
Part-time
Per Diem
Dues Amount
$0.00
Total
* draft
COPE Amount
By donating to COPE, we’re able to fight for your pension, good legislation, and elected officials who support you and your professions. Donating to COPE is the most effective way for your voice to be heard.
COPE Amount Values
$0
$2.5
$5
$10
other
Other Amount
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Authorize
I agree to be a member of Health Professionals and Allied Employees, authorize Health Professionals and Allied Employees to represent me to the fullest extent of the law, and accept the terms of the agreement below.
I hereby request and voluntarily authorize my employer to deduct from my earnings and to pay to HPAE an amount equal to regular monthly dues or fees uniformly applicable to members of HPAE-represented bargaining units, and (if owing) a standard initiation fee. This authorization shall remain in effect and shall be irrevocable unless I revoke it by sending written notice to HPAE during the period not less than thirty (30) days and not more than forty-five (45) days before (i) the annual anniversary date of this agreement or (ii) the date of termination of the applicable contract between the employer and HPAE, whichever occurs sooner. This authorization is irrespective of my membership in HPAE and shall be automatically renewed as an irrevocable check-off from year to year unless I revoke it in writing during the window period. Dues, contributions, or gifts to HPAE, AFT/AFL-CIO, may not be deductible for federal income tax purposes; however, dues may be deductible as a business expense.
Authorize COPE
YES, I want a voice in governmental decisions on salaries, healthcare, retirement, and other benefits and laws affecting HPAE members.
If provided for in the applicable contract, I hereby authorize my employer to deduct from my wages in each pay period the amount designated below and to remit such deduction to the HPAE Committee on Political Education (“COPE”). I understand that this money may be used to make political contributions and expenditures as authorized by the State Executive Council of HPAE in connection with elections for Local, State, and Federal offices. The contribution amounts indicated below are only suggestions and I may choose not to contribute or to vary my contribution amount without reprisal from my Union or my employer. This authorization is made voluntarily and is not a condition of my employment or membership in the Union. This authorization may be revoked or modified at any time by my notification to HPAE in writing. This contribution is in addition to Union dues. Contributions or gifts to HPAE COPE are not deductible as charitable contributions for federal income tax purposes. Only U.S. citizens or lawful permanent residents are eligible to contribute to HPAE COPE.
Print your name
Date
Date
E.g., 2024-12-04
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Math question
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