CEUI 511 Membership Sign-up Form

Email

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We Are Stronger Together!
Join us for a stronger voice in our communities.

First Name*

Middle Name

Last Name*

Street Address*

City*

Zip Code*

State*

Personal or Work Email*

Mobile Phone*

Date of Birth*

By submitting your cell phone number you are agreeing to receive periodic text messages from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages.

Employment

Job Title*

Employee #

Hire Date*

Agency Name*

Agriculture Experimental Station Location*

Attorney General Agency Location*

Children & Families Agency Location*

Commission on Arts Agency Location*

Corrections Agency Location*

CT Airport Authority Agency Location*

CT Lottery Corp Agency Location*

CT State Colleges & Universities Agency Location*

CTECS (Education) Agency Location*

DDS (DMR) Agency Location*

Dept of Administrative Services Location*

Dept of Aging & Disability Services Location*

Dept of Aging/Serv for the Blind Location*

Dept of Agriculture Location*

Dept of Banking Agency Location*

Dept of Consumer Protection Location*

Dept of Transportation Location*

DMHAS Agency Location*

Environmental Protection Location*

Fire Prevention & Control Agency Location*

Homeland Security Agency Location*

Human Rights Agency Location*

Insurance Agency Location*

Labor Agency Location*

Medical Examiner Agency Location*

Military Agency Location*

Motor Vehicle Agency Location*

Office of Policy & Management Agency Location*

Public Health Agency Location*

Public Safety/State Police Agency Location*

Public Works Agency Location*

Revenue Service Agency Location*

Secretary of State Agency Location*

Social Services Agency Location*

Special Revenue Agency Location*

State Comptroller Agency Location*

State Library Agency Location*

Treasurer Agency Location*

UConn Health Center Agency Location*

University of Connecticut Agency Location*

Veterans Affairs Agency Location*

Membership Authorization

Yes, I want to join with my fellow employees and become a member of CEUI/SEIU Local 511. I hereby request and voluntarily accept membership in CEUI/SEIU Local 511. This means I will receive the benefits and abide by the obligations of membership in CEUI/SEIU Local 511 as set forth in both the Constitution and Bylaws of CEUI/SEIU Local 511 and the Service Employees International Union (“SEIU”). I authorize CEUI/SEIU Local 511 to act as my representative in collective bargaining over wages, benefits, safety, and other terms and conditions of employment with my employer and as my exclusive representative where authorized by law. 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.

Signature*

Dues Deduction/Check-off Authorization

I hereby request and voluntarily authorize my employer to deduct bi-weekly from my earnings and transmit to CEUI/SEIU Local 511 an amount equal to the regular dues uniformly applicable to members of CEUI/SEIU Local 511. This authorization shall remain in effect unless I revoke it by sending written notice via U.S. mail to CEUI/SEIU Local 511 during the period not less than thirty (30) days and not more than forty-five (45) days before (1) the annual anniversary date of this agreement or (2) the date of termination of the applicable contract between the employer and CEUI/SEIU Local 511, whichever occurs sooner. This authorization shall be automatically renewed from year to year unless I revoke it in writing during the window period, even if I have resigned my membership in CEUI/SEIU Local 511.

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 members benefit from everyone’s commitments because they help to build a strong union that is able to plan for the future.

Contributions or gifts to CEUI/SEIU Local 511 are not tax deductible as charitable contributions.

Signature*

We Are Stronger Together! Join us for a stronger voice in our communities.

Employment

Membership Authorization

Dues Deduction/Check-off Authorization

We Are Stronger Together!
Join us for a stronger voice in our communities.