UAW Local 5000 2022 - 2023 Page 39 of 45
APPENDIX I
SPECIAL OFFICIAL APPLICATION FOR MEMBERSHIP
INTERNATIONAL UNION, UNITED AUTOMOBILE, AEROSPACE & AGRICULTURAL IMPLEMENT
WORKERS OF AMERICA (UAW)
DETROIT, MICHIGAN 48214 Date___________________
Name L. U. No._____________________________
Address City State Zip _______________
Dept. Social Security No.________________________________________
I hereby designate, select and empower the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW), its agents or
representatives, to act for me as my exclusive representative for the purposes of collective bargaining in respect to rates of pay, wages, hours of employment or other
conditions of employment, and to enter into contracts with my employer covering all such matters, including contracts requiring the continuance of my membership in said
Union as a condition of my employment or continued employment, and contracts requiring the employer to deduct, collect, or assist in collecting from my wages or a regular
supplemental unemployment benefit payable under its supplemental unemployment benefit plan any dues and fees payable to said Union; and I hereby revoke every
selection or designation which in any manner may heretofore have been made by me, of any other representative for any of such purposes.
I further irrevocably designate, authorize and empower the said Union exclusively too appear and act for me and in my behalf before any board, court, committee or
other tribunal in any matter affecting my status as an employee, or as a member of said Union, and exclusively to act as my agent to represent and bind me in the
presentation, prosecution, adjustment and settlement of all grievances, complaints or disputes of any kind or character arising out of the employer-employee relationship as
fully and to all intents and purposes as I might or could do if personally present.
I pledge my honor to faithfully observe the Constitution and laws of this Union and the Constitution of the United Sates (or the Dominion of Canada as the case may be);
to comply with all the rules and regulations for the government thereof; not to divulge or make known any private proceedings of the Union; to faithfully perform all the duties
assigned to me to the best of my ability and skill; to so conduct myself at all times as not to bring reproach upon my Union, and at all times to bear true and faithful allegiance
to the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW).
CONTRIBUTIONS OR GIFTS TO THE UAW ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL INCOME TAX PURPOSES.
(Applicant’s Signature)_______________________________________________________________________________________
(Witness)__________________________________________________________________________________________________
AUTHORIZATION FOR CHECK-OFF OF DUES
TO THE COMPANY Date________________________
I hereby assign to Local Union No. , International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW), from any
wages earned or to be earned by me or a regular supplemental unemployment benefit payable under its supplemental unemployment benefit plan as your employee (in my
present to in any future employment by you), such sums as the Financial Officer of said Local Union No. may certify as due and owing from me as membership dues,
including an initiation or reinstatement fee and monthly dues in such sum as may be established from time to time as union dues in accordance with the Constitution of the
International Union, UAW. I authorize and direct you to deduct such amounts from my pay and to remit same to the Union at such times and in such manner as may be
agreed upon between you and the Union at any time while this authorization is in effect.
This assignment, authorization and direction shall be irrevocable for the period of one (1) year from the date of delivery hereof to you, or until the termination of the
collective agreement between the Company and the Union which is in force at the time of delivery of this authorization, whichever occurs sooner; and I agree and direct that
this assignment, authorization and direction shall be automatically renewed, and shall be irrevocable for successive periods of one (1) year each or for the period of each
succeeding applicable collective agreement between the Company and the Union, whichever shall be shorter, unless written notice is given by me to the Company and the
Union, not more than twenty (20) days and not less than ten (10) days prior to the expiration of each period of one (1) year, or of each applicable collective agreement
between the Company and the Union whichever occurs sooner.
This authorization is made pursuant to the provisions of Section 302(c) of the Labor Management Relations Act of 1947 and otherwise.
CONTRIBUTIONS OR GIFTS TO THE UAW ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL INCOME TAX PURPOSES.
__________________________________________________
(Signature of Employee here) (Address of Employee)
__________________________________________________
(Type or print name of Employee here) (City) (State) (Zip)
__________________________
(Date of Signature) (Employee Clock Number) (Social Security Number) (Date of Delivery to Employer)