SEIU 721
Southern California Public service Workers
SEIU 721 COPE Application
Employer Name
EmployeeID
SSN#
LastName
FirstName
M.I.
DateOfBirth
Gender
HomeAddress
City
State
ZipCode
HomePhone
WorkPhone
Extension
CellPHone
Email
Item#
JobTitle
HireDate
Annual Salary
WorkStatus
Shift
Dept#
Department Name
Facility Name
FacilityAddress
City
State
ZipCode
Division(if applicable)
Unit/Floor/Room/Other
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I voluntarily authorize my employer to deduct:
 
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I agree to The 
COPE Agreement
By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to [any text from us or 787753] to stop receiving messages. Text HELP to 787753 for more information.
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SEIU 721 Staff
Co-Worker
 
 
COPE Agreement
I voluntarily authorize my union, SEIU Local 721, to file this payroll deduction with my employer and for my employer to forward that amount specified to SEIU Local 721 COPE.
I understand that: 1) I am not required to sign this form or make COPE contributions as condition of my employment by my employer or membership in the union; 2) I may refuse to contribute without any reprisal; 3) Only union members and executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to SEIU Local 721 COPE; 4) The amounts on this form are merely a suggestion, and i may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer; 5) SEIU Local 721 COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections.
Contributions to SEIU Local 721 COPE are not deductible for federal income tax purpose. This authorization shall remain in effect until revoked in writing by me.
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