Date __________________________ Member’s signature _______________________________________________________
I wish to be represented by CSEA as my sole and exclusive collective bargaining representative for all matters relating to wages, hours and other terms and conditions of employment.
I hereby apply for membership in CSEA and agree to abide by the Constitution and Bylaws and written policy of CSEA at any level. I hereby separately authorize and direct my employer to deduct from my salary and
pay to CSEA its regular rate of dues and chapter dues. If an increase or decrease in dues is adopted by CSEA members, this authorization shall include the then-established dues and no new authorization shall be
required. This dues authorization is voluntarily made in order to pay my fair share of CSEA’s costs for representing me, and is not conditioned on my present or future membership in CSEA. This authorization shall be
irrevocable for a period of one year from the date of my signature, and shall be automatically renewed for successive annual periods unless revoked by written notice to my employer and CSEA within a window period
between 40 days and 30 days prior to the anniversary date of my signature.
*NOTE: Your CSEA membership in good standing for the above purposes and for establishing voting rights and eligibility to hold CSEA offices will not commence until the first of the month after the first payroll deduction
has been taken, unless cash payment for the interim period is remitted with this application.
SUPPORT CSEA’S POLITICAL EDUCATION FUND
I hereby authorize my employer to deduct each month the sum of: ● $3.00 ● $5.00 ● $10.00 ● Other $_________ (Please select your choice).
I understand that my contributions will be used to advance the political interests of classified employees, public education, working families and the labor movement by supporting federal, state and local candidates, and
that any contributions over $200 per calendar year will be used to support or oppose ballot measures and pass school bonds and parcel taxes. I understand that this authorization is voluntary and that I may refuse to
contribute without reprisal. The amounts shown are only suggestions. You are free to indicate any amount you choose and there will be no favor
or disadvantage by reason of the amount of your contribution or your decision not to contribute. This authorization may be revoked in writing
at any time. Contributions to the CSEA Political Education Fund are not deductible for federal income tax purposes. The effective date will be the
date of the next payroll following receipt of this application by the employer.
Initial here
California School Employees Association
PACE of CSEA Victory Club
Federal and State PAC
PLEASE PRINT
Last 4 Digits of SSN ______________ Chapter Name ________________________ Chapter Number __________ E-mail ____________________________________
____________________________________________________________________________________________________________________________ DOB |________|________|_____________| ● Female ● Male
Last Name Legal First Name MI Mo Day Yr
_________________________________________________________________________________________________________________________________ (_________)_________________________
Street Address City State Zip Home Telephone
_________________________________________________________________________________________________________________________________ (_________)_________________________
Mailing Address (if different) City State Zip Cell Telephone
__________________________________________________ ____________________________________________ __________________________ (_________)__________________________
District/Employer Work Site Employee number Work Telephone
Select one: ● 9
Month Employee
● 10
Month Employee
●
11 Month Employee
●
12 Month Employee
●
Other
_________________________
Select one:
● 1.
Maintenance & Operations
● 2.
Office & Technical
● 3.
Food Service
● 4.
Transportation
● 5.
Paraeducator
● 6.
Special Services
FOR OFFICE USE:
CSEA ID _________
AREA ____________
AFL-CIO
CALIFORNIA SCHOOL EMPLOYEES ASSOCIATION
Application for Membership and Salary Deduction Authorization
Mailing address:
California School Employees Association
2045 Lundy Avenue, San Jose, CA 95131
1045_0318
www.csea.com
