MICA Staff Online Authorization Form

The collective bargaining agreement between MICA and SEIU Local 500 provides that all employees who are employed by the College and covered by this Agreement must either voluntarily become members of the Union or shall be required as a condition of continued employment to pay to the Union each month a service charge as a contribution toward the cost of administration of this Agreement and representation by the Union, beginning no later than thirty (30) days after the initial date of hire.

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Contact Information

First Name Middle Name (Optional) Last Name

Date of Birth

Street Address Address Line 2 (Optional)

Postal Code City State/Province

Personal Email Home Phone (Optional) *Mobile Phone (Optional)

*By providing my phone number, I understand that SEIU, its local unions, and affiliates my use autmated calling technologies and/or text message me on my cellular phone on a periodic basis. Local 500 and 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. Test HELP to 787753 for more information. Privacy Policy

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(Optional)

Employment Information:

MICA ID #

Estimated Annual Salary:

$16, 000 or more

$5,500 - $15,999.99

Less than $5,500

Job Title:

Worksite/Department

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.

Membership Authorization (Optional)

Yes, I want to be a member of SEIU Local 500.

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.

Agency Fee Payer Authorization (Optional)

I wish to be an Agency Fee payer of SEIU Local 500.

AUTHORIZATION FOR PAYROLL DEDUCTION

In payment for initiation fees and membership fees or agency fees to SEIU Local 500, I hereby authorize and direct MICA to deduct from my pay an amount equal to the dues or agency fees in the amounts specified by SEIU Local 500 and to pay that amount to SEIU Local 500 in accordance with the terms of the Collective Bargaining Agreement between MICA and SEIU Local 500. This authorization will remain in effect each year or until I cancel it in writing and receive it from the Union. It will remain in effect if my employment with MICA is terminated and I am later re-employed by MICA.

Note: Dues, fees, and assessments paid to the Union are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.

Authorization for Payroll Deduction (Optional)

Yes, I authorize payroll deduction.

When Workers Unite, Politicians Listen
Building Our Political Power

COPE, which stands for 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 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.

COPE (Optional)