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: _____/_____/_____
