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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SEIU 721 Staff
Co-Worker
 
 
Membership Agreement
Yes, I want to join my fellow employees and become a member of SEIU Local 721! I request and voluntarily accept membership in SEIU Local 721 and its successors or assigns(collectively "Local 721").This means I will receive benefits and abide by the obligations of membership set forth in both Local 721's and the Service Employees International Union's Constitutions and Bylaws.I authorize Local 721 act as my representative in collective bargaining over wages, benefits and other terms/conditions of employment with my employer & as my exclusive representative where authorized by law.I know that union membership is voluntary and not a condicion of employment & that I can decline to join without reprisal
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Dues Deduction Agreement
I request and voluntarily authorize my employer to deduct from my earnings & to pay to Local 721 and its successors and assigns(collectively "Local 721") an amount to the regular monthly dues uniformly applicable to members of Local 721. This authorization shall remain in effect unless I revoke it by providing notice to Local 721 via U.S. mail(or other method if permitted by Local 721's policies) within 15 days before or after (1) the annual anniversary agreement date of this agreement Or (2) the termination of the applicable collective bargaining agreement between my employer and union (my "window periods").This authorization will renew automatocally from year to year even if I have resigned my membership, unless I revoke it during a window period and as required by Local 721's policies. This authorization is voluntary and is not a condition for my employment and I can decline to agree to it without reprisal. I understand that all members benefit from everyone's commitment because they help to build a strong union and is able to plan for the future. 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 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.
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