INSTRUCTIONS FOR SELECTING YOUR UNION STATUS:

Employees must select either Membership or Agency Fee Payer. When you choose your union status, in order to have your deductions taken from your paycheck, make sure you authorize the Payroll Deduction section of this form.

STEP 1 - Choose Your Union Status:

MEMBERSHIP AUTHORIZATION

I request and voluntarily accept membership in SEIU Local 500 and I agree to abide by the obligations of membership set forth in the Constitution & Bylaws of both Local 500 and the Service Employees International Union ("SEIU"). I authorize SEIU Local 500 to act as my exclusive representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer. I know that membership in the union is voluntary and is not a condition of my employment and that I can decline to join without reprisal.

AGENCY FEE PAYER AUTHORIZATION

I do not wish to be a member of SEIU Local 500 and will pay the agency fee as required. I understand by making this choice, I relinquish my right to vote on my contract, serve on committees, and give up access to member benefits. To obtain information sufficient to gauge the propriety of the agency fee, along with a description of the procedures to be followed in accordance with your rights under the law, click here for more information.

STEP 2 - Choose How To Pay:

AUTHORIZATION FOR PAYROLL DEDUCTION

Accordingly, as payment for membership dues or agency fees to SEIU Local 500, I request and voluntarily authorize my employer to deduct from my earnings and to pay to Local 500 an amount equal to the dues or agency fees in amounts specified by Local 500, at times and in a manner agreed upon between Local 500 and the employer. This authorization will remain in effect unless I revoke it by sending written notice via U.S. mail to Local 500 during the periods not less than 30 days and not more than 45 days before either (1) the annual anniversary date of this agreement, or (2) the date of termination of the applicable collective bargaining agreement between the employer and Local 500. This authorization shall be automatically renewed from year to year unless I revoke it in writing during a window period, even if I have resigned my membership. This authorization will remain effective if my employment with the employer is terminated and I am later re-employed by the employer.

This authorization is voluntary and is not a condition of my employment, and I can decline to agree to it without reprisal. I understand that all bargaining unit employees benefit from everyone's commitments because they help to build a strong union that is able to plan for the future.

Dues and fees paid to Local 500 are not tax-deductible as charitable contributions.

When Workers Unite, Politicians Listen
Building Our Political Power

COPE, which stands for the Committee on Political Education, is a Political Action Committee (PAC) fund used to support issues important to working families and hold politicians accountable. Union dues cannot be used for political purposes, therefore members are making voluntary contributions to SEIU 500's COPE PAC fund so that we can help elect candidates who stand up for issues important to working families. Please select the amount you wish to contribute below.

SEIU  Local 500 COPE (PAC) CHECKOFF AUTHORIZATION

I authorize SEIU Local 500 to file this payroll deduction form with my employer, and for my employer to withhold the amount specified above to forward to SEIU Local 500 as a contribution to SEIU Committee on Political Education (“SEIU COPE”). 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 the 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 amount on this form is merely a suggestion, and I may contribute more or less by this or other means without fear of favor or disadvantage from my union 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 Local 500.

Voluntary contributions will be deducted in the authorized amount beginning on the first full pay period following receipt of this authorization by payroll. I hereby authorize my employer to deduct :(the amount specified below) from my paycheck each pay period for SEIU COPE, subject to the terms set forth above, under SEIU COPE CHECKOFF AUTHORIZATION.