Authorization For Representation

Fill out form, print and send to your local 100 chapter. click here for addresses.

I hearby authorize Local 100 SEIU, AFL-CIO, to represent me for the purpose of collective bargaining with my employer, and to negotiate and conclude all agreements respecting wages, house and conditions of employment. I understand that this information may be used by the union to obtain recognition from my employer without an election.

Address 1:
Address 2:
City, State, Zip , ,
Employed at:
Hourly Wage:


Authorization to Deduct Dues

[last, first, middle]
Social Security Number

Effective ____________________, I hereby request and authorize you to deduct from my earnings each payroll period, an amount sufficient to provide for the regular payment of the current rate of monthly union dues and inititation fee (if owing) established by Local 100, Service International Union, AFL-CIO, or an equivilent amount. The amount shall be in accordance with the provisions of the constitution of Local 100 and shall be applicable of my membership status in the Union. The amount deducted shall be irrrevocable for the period of one (1) year from the date thereof, and shall be automatically recieved and irrevocable for successive similar periods unless revoked by written notice to the employer and to the Treasurer of Local 100 within the period of fifteen (15) days prior to the anniversary of my checkoff.