Membership and Authorization for Dues Deduction

Yes, I want to join Child Care Providers United-Pennsylvania.

First Name

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Social Security Number (last four digits only)

Cell Phone †

† By providing my cell phone number I consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. My carrier’s rates may apply. I may modify my preferences by calling the Union at 215-735-6350 or emailing the Union at LHines@1199cnuhhce.org.

Home Phone

Personal Email

Child Care Facility

Facility Location (County)

Authorization

I hereby apply for membership in Child Care Providers United-Pennsylvania (CCPU-PA/AFSCME/SEIU) (hereafter “the Union”), and agree to abide by its governing documents. By this application, I authorize the Union and its successor and assign to act as my exclusive representative with respect to terms and conditions relating to my work as a child care provider in Pennsylvania.

Effective immediately, I authorize the State of Pennsylvania and its payroll processing agency (hereafter ”State”) to deduct from my earnings, and forward to the Union, the required amount of union dues as certified by the Union and as may be adjusted periodically.

This voluntary authorization and assignment shall be irrevocable, whether I am or remain a member of the Union, for a period of one year from the date of execution or until the termination date of the collective-bargaining agreement (if there is one) between the State and the Union, whichever occurs sooner, and for year to year thereafter unless I give both the State and the Union written notice of revocation not less than ten (10) days and not more than twenty (20) days before the end of any yearly period or during the last fifteen (15) days prior to the expiration of the applicable collective-bargaining agreement.

Payments to the Union are not deductible as charitable donations for federal income tax purposes. However, state law may extend favored tax treatment.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.

Yes! I want to join Leaders in Action. Sign me up to:

Join us in talking to other providers

Get involved in the political process

Communicate about worker issues online

Welcome new members to our union