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Kansas Organization of State Employees (KOSE) Membership Form
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personal-information-1
First Name
*
Middle Name
Last Name
*
billing-address
Mailing Country
*
United States of America
Mailing Address
*
Mailing City
*
Mailing State
*
- Select -
Alabama
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Arkansas
California
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Connecticut
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District of Columbia
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Maine
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Michigan
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Ohio
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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
Work Phone
Preferred Phones
preferred
preferred
preferred
Personal E-mail
*
Work E-mail
Work Location
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Employee ID number
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Employer
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Job Title
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Agency
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Recruited by
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Would you like to receive text messages from KOSE regarding important information?
Yes
No
payroll-deduction
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Select your membership category
Select your membership category
Up to $13.99
$14 - $14.99
$15 - $15.99
$16 - $16.99
$17 - $17.99
$18 and above
Dues Amount
$0.00
Total
* draft
privacy-policy
legal-wrapper
Authorize
I agree to be a member of Kansas Organization of State Employees - Payroll Deduction, authorize Kansas Organization of State Employees - Payroll Deduction to represent me to the fullest extent of the law, and accept the terms of the agreement below.
I the undersigned, an employee of the above-listed employer, hereby authorize my employer to make regular payroll deductions from my earnings for the amount certified by KOSE for membership dues. This authorization will remain in effect for not less than 180 days. Thereafter notification to drop membership shall be made in writing and mailed to the union.
Print your name
Date
Date
E.g., 2024-11-13
Signature field is required
CAPTCHA
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Math question
*
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