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Application for Membership USA

Form No. 107

Date/Time*
:  

* Mandatory Fields

Name*
Address*
Date of Birth*
Date of Hire
Industry Where You Are Employed
How Did You Become An I.B.E.W.® Member?
Gender**
Race and Ethnicity**

** Submission of this information is voluntary and will be kept confidential. The particular categories of gender, race, and ethnicity collected are those sought by applicable federal laws
under which certain local unions must report such information on an aggregate and summary basis to the federal government. If you choose not to self-identify, the federal government may
require this information to be determined by visual survey and/or other available information.

Are You A Veteran Of The Armed Forces?
Registered Voter?
Have You Ever Been A Member Of The I.B.E.W.®?

OBLIGATION OF I.B.E.W. ®

"I, the undersigned, in the presence of members of the International Brotherhood of Electrical Workers®, promise and agree to conform to and abide by the Constitution and laws of the I.B.E.W.® and its Local Unions. I will further the purposes for which the I.B.E.W.® is instituted. I will bear true allegiance to it and will not sacrifice its interest in any manner."

Applying to
Application Date*
Use your mouse or finger to draw your signature above

Dues Deduction Authorization

I hereby authorize

to deduct dues and initiation fees from my pay and to pay the same to

In accordance with the following

I hereby voluntarily authorize my Employer (identified above), or its successors or assigns (“the Employer”) to deduct from my pay each pay period an amount of dues and initiation fees fixed in accordance with the Bylaws of the Local Union identified above or its successors or assigns (“the Union”) and the Constitution of the International Brotherhood of Electrical Workers, or such lesser amount as required by law, and to pay same to the Union in accordance with the terms of the bargaining agreement between the Employer and the Union.

This authorization shall be irrevocable for a period of one year from the date hereof or until the termination date of the bargaining agreement between the Employer and the Union, whichever occurs sooner, without regard to whether I am a member of the Union during that period, and shall automatically renew and be irrevocable for successive periods of one year unless I give the Employer and the Union written notice of revocation during the ten (10) day period prior to the anniversary of this authorization or during the ten (10) day period beginning on the termination date of the agreement, whichever comes first.

I recognize that signing this authorization of payroll deductions is not a condition of employment, and that my authorization, and the continuation of such authorization from year to year, is voluntary and applies regardless whether I am a union member.

I understand that under current law the payments covered by this authorization are not deductible as charitable contributions for federal income tax purposes.

Date
Name*
Use your mouse or finger to draw your signature above

THIS PORTION TO BE FILLED OUT BY L.U. FINANCIAL SECRETARY

Initiation Date*
Type Of Membership*
PAID $2.00 Pension Adm. Fee?*