Request for Exclusive Representation

First Name

Middle Initial

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

Employee ID

Personal Email

Cell Phone †

† By providing my cell phone number, I understand that AFSCME and its affiliates may use automated calling technologies and/or text message me on my cell phone on a periodic basis. Carrier message and data rates may apply to such texts. I may modify my preferences at afscme.org/tcpa.

Authorization

By signing this card, I the undersigned, State of Michigan classified employee, wish to be exclusively represented by the Michigan State Employees Association/AFSCME Local 5 under the provisions of Chapter 6 of the Civil Service Commission Rules. Consent is also given to the State of Michigan to deduct a sum equal to one hour of pay each two-week pay period from any accrued wages due to me and remit the same to the Michigan State Employees Association/AFSCME Local 5 for payment of my union dues. Additionally I hereby give consent to increase or decrease the specific named deduction each two week pay period to that of any amount determined by the Union in accordance with Article XVII of the Constitution (as amended) of the Michigan State Employees Association.

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.

Date Signed