A&R Membership Card Registration

First Name
*

Last Name
*

Employee #
*

Home Mailing Address
*

City, State, and Zip Code
*

Mobile #

Mobile Phone Provider

Home e-mail

Home Phone #

Work Phone #

Date of Birth
*

MM

/

DD

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YYYY

Gender

Male

Female

Clear selection

State Agency
*

Agency Location
*

Official Job Title
*

Date of State Hire

MM

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DD

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YYYY

Date of Hire into A&R

MM

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DD

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YYYY

Salary Grade

Step

Membership Authorization
*

Y

By checking this box, I elect to become a member of A&R Local 4200, AFT-CT, AFT, AFL-CIO. I hereby request and voluntarily accept membership in A&R Local 4200. I authorize A&R Local 4200 to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer.

Dues Deduction/Checkoff Authorization
*

Y

By checking this box, I authorize my employer to deduct from my earnings the regular dues payable to A&R Local 4200. This authorization shall be irrevocable unless i revoke it by sending written notice via U.S. Mail to both the employer and A&R Local 4200 during the window period, February 1 -28 of any year. This authorization shall be automatically renewed from year-to-year unless revoked in writing during the window period.

Y

By checking this box, I authorize my employer to deduct from my earnings the regular dues payable to A&R Local 4200. This authorization shall be irrevocable unless i revoke it by sending written notice via U.S. Mail to both the employer and A&R Local 4200 during the window period, February 1 -28 of any year. This authorization shall be automatically renewed from year-to-year unless revoked in writing during the window period.