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Membership Application NJ Public Sector
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YES! I want to join with my colleagues and become a member of the Health Professionals & Allied Employees, AFT/AFL-CIO (“HPAE”). I voluntarily authorize HPAE, its agents, representatives, and successors, to act for me as a collective bargaining representative in all matters pertaining to wages, benefits, and other terms and conditions of employment. 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
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Middle Name
Last Name
*
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Mailing Country
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United States of America
Mailing Address
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Mailing City
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Mailing State
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- 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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Date of Birth
Date
E.g., 2024-10-11
Home Phone
Mobile Phone
Work Phone
Preferred Phones
preferred
preferred
preferred
Personal E-mail
*
Work E-mail
Work Location
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Recieve text messages
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Yes
No
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Employee ID:
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Employer:
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University Hospital
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Date of Hire
*
Date
E.g., 2024-10-11
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Job Title:
Job Title:
STAFF NURSE
ADVANCED PRACTICE NURSE
NURSE ANESTHETIST
FLIGHT NURSE
STAFF NURSE PD
CASE MANAGEMENT COOR
RESEARCH NURSE CLINICIAN
NURSE CLINICIAN
NURSE ANESTHETIST PD
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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 time
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 recognize the need for a strong union and believe everyone represented by our union should pay their fair share to support our union’s activities. I hereby request and voluntarily authorize my employer to deduct from my earnings an amount equal to regular monthly dues or fees uniformly applicable to members of HPAE-represented negotiation units, and (if owing) a standard initiation fee, and authorize my employer to transmit this deduction to HPAE.
This authorization is irrespective of my membership in HPAE and shall remain in effect and shall be irrevocable unless I provide written notice to my employer requesting to revoke it. Such notice of revocation of authorization for the payroll deduction of dues shall be effective on the 30th day after my anniversary date of employment, as required by the “Workplace Democracy Enhancement Act”, P.L.2018, c.15 (C.34:13A-5.11 et seq.). 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., 2024-10-11
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