Membership Application/Update Date MM slash DD slash YYYY Faculty or Coach Faculty Coach Name First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Home/Cell)Phone (Office)Email (Campus) Email (Alternate) UniversityPlease ChooseBloomsburgCaliforniaCheyneyClarionEast StroudsburgEdinboroIndianaKutztownLock HavenMansfieldMillersvilleShippensburgSlippery RockWest ChesterDepartment Employee ID Number Campus or Other University Gender Past PASSHE Employment?Complete only if break in service Yes No University YearAPSCUF Member? Yes No With this card and my signature, I request and accept membership in the Association of Pennsylvania State College and University Faculties (APSCUF) and I agree to abide by the APSCUF bylaws. I authorize APSCUF to act as my exclusive representative in collective bargaining over wages, hours and other terms and conditions of employment with Pennsylvania's State Systems of Higher Education (STATE SYSTEM). Effective immediately, I hereby voluntarily authorize and direct the State System to deduct APSCUF membership dues or their equivalent from my pay each pay period, regardless of whether I am or remain a member of APSCUF, the amount of dues certified by APSCUF, and as they may be adjusted periodically by APSCUF. I further authorize the State System to remit such amount monthly to APSCUF. This voluntary authorization and assignment shall remain in effect, regardless of whether I am or remain a member of APSCUF, for a period of one year from the date of the execution of this authorization or until the termination date of the collective bargaining agreement between the State System and APSCUF, whichever occurs sooner, and for years to come, unless I give the State System and APSCUF written notice of revocation during the fifteen (15) days before the annual anniversary date of this authorization or, during the fifteen (15) days before the date or termination of the appropriate collective bargaining agreement between the State System and APSCUF, whichever occurs sooner. This authorization shall automatically renew as an irrevocable check-off from year to year unless I revoke it in writing during the revocation period, even if I resigned my membership in APSCUF. This authorization shall be valid while I remain employed by the State System in the APSCUF bargaining unit, unless I notify APSCUF and the State System in writing during the revocation persiod that this authorization is revoked. I recognize that my agreement for the continuation or automatic renewal of my authorization for dues check-off, even if I have resigned my membership, is volutary and not a condition of employment. Union dues may be tax deductible as ordinary and necessary business expenses.Signature*By providing my cell phone number, I understand that APSCUF may use automated calling technologies and/or text message me on my cell phone on a periodic basis. APSCUF will not charge for text message alerts, but carrier message and data rates may apply to such texls. To opt out, follow the instructions provided In such messages, or visit www.APSCUF.org/issues-and-advocacy/negotiations-updates. Δ Voluntary CAP Payroll Deduction Authorization I hereby authorize the State System of Higher Education to deduct from earnings each paycheck, the amount certified below as a voluntary contribution to APSCUF's political action committee (APSCUF/CAP). My contribution is voluntary and I understand that is not required as a condition of membership in any organization. I understand that contributions to APSCUF/CAP are not deductible as charitable contributions for federal income tax purposes. This authorization shall be valid while I remain in the employ of the State System of Higher Education unless I notify APSCUF and the State System in writing that this authorization is revoked.Date MM slash DD slash YYYY Name First Last Employee ID Number UniversityPlease Choose:BloomsburgCaliforniaCheyneyClarionEast StroudsburgEdinboroIndianaKutztownLock HavenMansfieldMillersvilleShippensburgSlippery RockWest ChesterPayroll DeductionPer pay period +$2.00 +$5.00 +$10.00 +$20.00 Other (Please specify amount) Please Enter a Specific Amount for Payroll DeductionI would like to receive email updates about CAP at this email address I am interested in the following CAP activities Fundraising Events Golf Outings Legislative Meet-and-Greets Signature Δ
