Membership Application

Join*

I want to join healthcare workers across the state for a stronger voice for quality healthcare, living wages, and good benefits. I accept membership in 1199SEIU United Healthcare Workers East and designate 1199 to act for me as collective bargaining agent in all matters pertaining to conditions of employment. I pledge to abide by the Constitution of 1199SEIU United Healthcare Workers East.

First Name*

Last Name*

Address*

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Address2

Enter your office, floor, apartment, or suite number (if applicable).

City*

State*

ZIP Code*

Best Phone to Reach You*

Phone Type (Best Phone)*

Select the type of phone you use at this number.

Second Phone

Phone Type (Second Phone)

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Email*

Password*

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Password Confirmation*

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Date of Birth*

Format: mm/dd/yyyy.

Organizer follow up

I want to get involved in 1199SEIU! Please have an organizer follow up with me.

Text Messages

I would like to receive 1199SEIU action alerts on my mobile phone. (Standard text messaging rates apply.)

Language Preference

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Requirements*

Yes, I meet the requirements listed under "Membership Requirements" on this page.

Section 2: Check Off Authorization*

Yes, I agree to all statements under "Section 2: Check Off Authorization" on this page.

Section 3: 1199SEIU Political Action Fund

Yes, I agree to all statements under " Section 3: 1199SEIU Political Action Fund" on this page.

PAC Witholding

I hereby authorize 1199SEIU United Healthcare Workers East to file this payroll deduction form on my behalf with my employer to withhold the amount I designate in this form per month and forward that amount to the 1199SEIU Massachusetts Political Action Fund, 498 Seventh Ave NY, NY 10018.

Other (fill in blank)

If you selected other, above, please enter a monthly contribution here.

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