City of Dallas Employee Application for Membership

North Texas Association of Public Employees - An Affiliate of United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, Allied Industrial and Service Workers International Union, AFL-CIO, CLC

First Name

Last Name

Street Address

Apartment, Suite, etc.

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Home Email

Work Email

Home/Cell Phone

Work Phone

Job Title/Department

Employee Number

Authorization

I hereby request and accept membership in the North Texas Association of Public Employees - an affiliate of the United Steel, Paper and Forestry, Rubber, Manufacturing, Energy, Allied Industrial and Service Workers International Union, AFL-CIO, CLC ("NTAPE/USW"), and I hereby authorize and designate the USW to act as my Representative for purposes of presenting grievances concerning my wages, hours of work and other working conditions and terms of employment.

I further authorize and request my employer to deduct from my earnings 1% per pay period, not to exceed $20 per month, which represents my membership dues to said organization. The amount is to be transmitted to the International Secretary/Treasurer of the USW. I also authorize the City of Dallas, City Manager, and City Secretary's Office to furnish to the North Texas Association of Public Employees all changes of address and telephone numbers that are furnished to the City from time to time. Names, addresses, E-mails and telephone numbers will be used by the North Texas Association of Public Employees Association for official business only. This authorization shall remain in effect until further notice from me in writing after the completion of a 12 month period or upon termination of my employment.

Signature

Sign above