UNITED NURSES ASSOCIATIONS OF CALIFORNIA/
UNION OF HEALTH CARE PROFESSIONALS, NUHHCE, AFSCME, AFL-CIO

Personal Information

First Name*

Last Name*

Middle Name

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Address*

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Australia Canada USA

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Job Information

Professional Title*

Professional License No.*

Date Hired*

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Employer*

Adventist Health White Memorial Montebello Bear Valley Community Healthcare District Doctors Hospital of Riverside Kaiser Permanente - Hawaii Kaiser Permanente - Northern California Kaiser Permanente - Southern California Maui Health System Naval Medical Center San Diego Prime Healthcare Services Sharp HealthCare Tenet Healthcare University of California VA Loma Linda Healthcare System

Work Area

Clinic Hospital

Affiliate*

Occupation

Facility

Unit/Dept

Status*

FT PT Per Diem/Short Hour

VOLUNTARY DEDUCTION AUTHORIZATION

EMPLOYER

AFFILIATE NAME

Pursuant to this Authorization and Assignment, the above-named Employer is requested to deduct from my pay, while I am employed within the collective bargaining unit of the Employer and irrespective of my membership status in the Union, a sum equal to the periodic dues, assessments, and/or fees, as designated by the Union. The Employer is requested to forward all sums promptly to the Union as designated above. The Union may advise the Employer from time to time of any changes to the said dues, assessments, and/or fees, and I request that the Employer immediately implement and deduct and forward the new sum(s) reflecting such change(s).

This Authorization and Assignment is voluntarily made in consideration for the cost of representation and collective bargaining, and is not contingent upon my present or future membership in the Union. This Authorization and Assignment shall remain in effect and shall be irrevocable unless I revoke it by sending written notice, with my signature, by U.S. mail or hand delivery to both the Employer and the Union no more than twenty (20) days and no less than ten (10) days immediately preceding the end of any yearly period subsequent to the date of this Authorization and Assignment or during the fifteen (15) day period immediately preceding the date of termination of the collective bargaining agreement in effect between the Employer and the Union, whichever occurs sooner, and shall be automatically renewed as an irrevocable check-off from year to year unless revoked as herein above provided.

I Agree

MEMBERSHIP APPLICATION

AFFILIATE NAME

I hereby request and accept membership in the above named Affiliate of the United Nurses Associations of California/Union of Health Care Professionals, NUHHCE, AFSCME, AFL-CIO, and of my own free will hereby authorize said Union, its officers, representatives and agents, to act for me as a collective bargaining agency in all matters pertaining to rates of pay/wages, hours of work, or other conditions of employment, and to enter into a Labor-Management Agreement which may require the continuance of my membership in said Union as a condition of my continued employment and may require the periodic dues and initiation fees uniformly required as a condition of acquiring or retaining membership.

I Agree