SEIU HCPA Membership Application - Private Sector
SEIU Healthcare Pennsylvania 1500 N. 2nd Street, Harrisburg, PA 17102
YES! I want to join my fellow employees and become a member of SEIU Healthcare Pennsylvania (SEIU HCPA).
I request and accept membership in SEIU HCPA and I agree to abide by the SEIU HCPA constitution on and by-laws. I authorize SEIU HCPA to act as my exclusive representative in collective bargaining over wages, benefits and other terms and conditions of employment with my employer.
First Name *
Your answer
Last Name *
Your answer
Employer *
Your answer
Date Hired
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Job Title
Your answer
Dept/Work Area
Your answer
Email *
Your answer
*Cell Phone
Eg. 1112223333
Your answer
*Home Phone
Eg. 1112223333
Your answer
Street Address *
Your answer
Zip Code *
Your answer
Date of Birth
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DD
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YYYY
Language Preference
Your Signature *
Full name for signature
Your answer
Date *
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YYYY
*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 787753 to stop receiving messages. Text HELP to 787753 for more information.
Membership Dues Deduction Authorization *
Required
Signature *
Full name for signature
Your answer
Yes! I'll contribute to help pass laws for safe staffing, affordable healthcare, and good jobs for working families.
I hereby authorize my employer to withhold the indicated amount bi-weekly to forward to SEIU HCPA as a contribution to SEIU Committee on Political Education (SEIU COPE). My signature shows that I agree with the terms below.
Bi-Weekly COPE Amount
COPE Signature
Your answer
This authorization is made voluntarily based on my specific understanding that: 1) I am not required to sign this form or make voluntary contributions to SEIU COPE as a condition of my employment or membership in the union; 2) I may refuse to contribute without reprisal; 3) Under law, only union members and executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to COPE; 4) The contribution amounts on this form are merely suggestions, and I may contribute more or less by this or other means without fear of favor or disadvantage from SEIU or my employer; 5) SEIU COPE uses the money it receives for political purposes – including, but not limited to, making contributions to and expenditures on behalf of candidates for federal, state, and local offices – and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU.

Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.

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