SEIU 721
Southern California Public service Workers
SEIU 721 Membership Application. Para la versión en español haga clic aquí.
Employer Name(required)
EmployeeID #(required)
SSN#
LastName(required)
FirstName(required)
M.I.
DateOfBirth
Gender
HomeAddress
City
State
ZipCode
HomePhone
WorkPhone
Extension
CellPhone
Email(required)
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 agree to the 
Membership Agreement
(required)
 
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I agree to the 
Dues Deduction Agreement
(required)
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.To unsubscribe, text STOP to 31996.For info, text HELP to 31996.
SEIU 721 MEMBER LIFE INSURANCE
Active SEIU721 members are automatically covered for $2,000 life insurance and an additional $2,000 for accidental death and dismemberment insurance ( a total of $4,000 if accidental death).
Primary Beneficiary
Relationship
Secondary Beneficiary
Relationship
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Self-Signed
SEIU 721 Staff
Co-Worker
 
 
Membership Agreement
I hereby voluntarily request and accept membership in SEIU Local 721 and authorize the Union as my designated exclusive bargaining agent to represent me and to negotiate and conclude on my behalf any and all agreements as to wages, hours and other conditions of work. I agree to be bound by the Constitution and Bylaws of the Union and by any contracts that may be in existence at the time of application or that may be negotiated by the Union.
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Dues Deduction Agreement
I further voluntarily authorize SEIU Local 721 to instruct my employer to deduct and remit to the Union, any dues, fees and general assessments from my paycheck and to adjust the amount of this deduction as may be required to comply with changes in premiums under existing agreements with insurance plans, or to comply with dues schedules and general assessments determined by the Union.Irrespective of my membership in the Union, deductions for this purpose shall remain in effect and be irrevocable unless revoked by me in writing in accorddance with applicable provisions in the memorandum of understanding or agreement between my employer and SEIU Local 721.In the absence of such provision, this authorization shall remain in effect and can only be revoked by me in writing during the period not less than thirty(30) days and not more than forty - five(45) days before the annual anniversary date of this authorization.This authorization will remain effective if my employment with the Employer ends and I am later re-employed by the Employer.
It is my responsibility as a member to notify the Union if I believe my deductions are incorrect or If I am no longer in a bargaining unit represented by SEIU Local 721.
While dues, fees and assessments to SEIU Local 721 are not tax deductible as charitable contributions for federal income tax purposes, they may be deductible under other provisions subject to various restrictions imposed by the Internal Revenue Code.
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