Membership Application NJ Public Sector

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 *

Mailing Address *

Mailing Suite

Mailing City *

Mailing State *

Mailing Zip Code *

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Home Phone

Mobile Phone

Work Phone

Preferred Phones

preferred

Personal E-mail *

Work E-mail

Work Location

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Recieve text message- Message and data rates may apply

Yes

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Employee ID:

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Employer:

University Hospital

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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

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If yes, where?

payroll-deduction

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Select your membership category

Dues Amount

$0.00

Total * draft

COPE Amount

Other Amount

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Authorize

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 negotiation units, and (if owing) a standard initiation fee.

This authorization is irrespective of my membership in HPAE and shall remain in effect and shall be irrevocable unless I revoke this authorization by providing written notice to my employer during the 10 days following each anniversary date of my employment as required by the New Jersey Workplace Democracy Enhancement Act, supplementing P.L. 1941, c.100 (C.34:13A-1 et seq.), and amending P.L. 1967, c.310. 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.

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