May 29, 2017
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Membership Application

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For Payroll deduction purposes, AFSCME Local 4041 must have an original signature 
on the completed card, we cannot accept an emailed or faxed copy.

AFSCME MEMBERSHIP APPLICATION
(Please print clearly)

Name: _______________________________________________________________

EIN# _____________  and/or   SS#______--_____--_____           DOB ____/____/____ 

Residential Address: _____________________________________________________

City: __________________________________ State: _________ Zip: _____________

Mailing Address: ________________________________________________________

City: _________________________________ State: _________ Zip: ______________

Home Email Address: ___________________________________@____________ 

Home Phone: ______________________   Cell Phone: ______________________

Employing Agency: ____________________________ Work Phone: _______________

Department: ________________________________ Work Site:____________________

Classification: _____________________         Date of Hire with State:____/____/____

Registered Voter:    Y    N           Assembly District: ________ Senate District: _________

AFSCME Chapter: __________________ Recruited By: _________________________

Date: _____/_____/______ Signature: _______________________________________

I understand that this application is for membership in AFSCME Local 4041, and authorizes AFSCME Local 4041 to represent me in matters pertaining to my employment with the State of Nevada.  This includes membership in the Political Information Committee, Inc. I HEREBY AUTHORIZE  my employer to deduct from my salary the membership dues and benefit program payment in effect at this time or as modified in the future. Membership dues are 1% of base compensation pay before taxes, each pay period; probationary employees dues are 1/2% during probationary period.

“Membership renews annually and will remain in effect unless cancelled 2 weeks prior to your anniversary date as outlined in NAC 281.260”.

Office Use Only:  Received: _____/_____/_____ Probation Period: _____/_____/_____Start Date: _____/_____/_____

Mail to:  AFSCME Local 4041, 504 E Musser Street, Suite 300, Carson City, NV 89701

 

 




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AFSCME Local 4041
Copyright © 2017, All Rights Reserved
Local 4041 Carson City Office • 504 East Musser , Suite 300 • Carson City, Nevada 89701 • (866) 455-5414 • Email
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