SERV Authorization Card

SERV Check Off Authorization

To: The Employer.

You are hereby authorized to deduct from my wages, commencing with the next payroll period, and remit to AFSCME New Jersey Council 63 (the “Union”):

Check one:

The regular monthly dues, initiation fees and assessments, as interpreted by applicable law, as fixed by the Union and as required as a condition of acquiring or maintaining membership in the Union. By electing this option, you are also authorizing the Union and/or its subordinate organizations, to represent you in connection with your employment with the Medical Center.

The regular monthly "Agency Fees" as interpreted by applicable law, which amount shall be provided by the Union to the Hospital on an annual basis.

This authorization is voluntarily made in consideration of the cost of representation and collective bargaining and is not contingent upon my present or future membership in the Union. This authorization shall be irrevocable for a period of one (1) year and only by way of written notice of same bearing my signature to both the Union and the Medical Center between December 15th and January 15th.

Note: In the event you elect to pay “agency” or “Beck” dues, and are presently a Union member, you still have an obligation to pay applicable union dues, assessments, and fees until you resign your Union membership consistent with its rules and procedures.

Other than revocation as set forth above, my “check-off” authorization shall only terminate upon (a) termination of employment; (b) transfer to a job other than one covered by the bargaining unit; (c) Layoff from work; or (d) an agreed unpaid leave of absence. Notwithstanding the foregoing, upon my return to work from any of the foregoing enumerated absences, the Medical Center shall immediately begin making the deductions I have authorized above.

Once the funds are remitted to the Union, their disposition thereafter shall be the sole and exclusive obligation and responsibility of the Union. This authorization is made pursuant to the provision of applicable law including Section 302(c) of the Labor Management Relations Act of 1947.

First Name

Middle Initial

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Employer

Employee Number

Department

Classification

Personal Email Address

Home Phone

Cell Phone †

† By providing my cell phone number I consent to receive calls (including recorded or autodialed calls, or texts) at that number from AFSCME and its affiliated labor, political and charitable organizations on any subject matter. My carrier’s rates may apply. I may modify my preferences by emailing membership@afscmenj.org or calling the Union at 609.586.9093.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.