Yes! I want to join with my fellow workers in organizing to win higher wages, benefits, and improved working conditions. I request and voluntarily accept membership in SEIU Healthcare Illinois & Indiana and its successors or assigns (collectively “SEIU HCII”). This means I will receive the benefits and abide by the obligations of membership set forth in both SEIU HCII’s and the Service Employees International Union’s (“SEIU”) Constitutions and Bylaws. I authorize SEIU HCII to act as my representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer, and as my exclusive representative where authorized by law. My membership shall be continuous, unless I resign my membership by providing notice to SEIU HCII via U.S. mail (or other method if permitted by SEIU HCII’s policies). I know that union membership is voluntary and is not a condition of my employment, and that I can decline to join without reprisal.

In the event my employer ceases payroll deductions, I agree to pay my membership dues directly to Service Employees International Union Healthcare Illinois & Indiana and its successors and assigns (collectively “SEIU HCII”). I authorize SEIU HCII to bill my credit or debit card account, make withdrawals from my bank account, or charge any other payment method I provide in the amount of my regular membership dues, as authorized below. I authorize SEIU HCII to initiate a recurring, automatic electronic funds transfer with my financial institution in order to deduct from the account provided an amount equal to my membership dues equaling $17.50 each two week pay period. The first funds transfer will occur on the first payroll date on or following the date of this authorization. This authorization shall remain in effect until I revoke my authorization in writing by U.S. mail to SEIU Healthcare Illinois & Indiana or by email to directpayrevocation@seiuhcil.org or any other method permitted by SEIU HCII policy. I acknowledge that revocation of this authorization does not alter my obligations as a member of SEIU HCII.

If the terms of this agreement change, SEIU HCII will notify me at the current email address on file with SEIU HCII at least ten days before the next funds transfer date impacted by the change. The dues amount may change if authorized according to the requirements of the SEIU HCII Constitution and Bylaws or the Service Employees International Union Constitution and Bylaws. If this happens, I authorize SEIU HCII to initiate a recurring, automatic electronic funds transfer in the amount of the new dues amount upon receiving notice from SEIU HCII. If I opt to pay by debit card or credit card, I recognize that I may be charged an additional service fee per transaction. In the case of checking and savings accounts, adjusting entries to correct errors are also authorized. I agree that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. SEIU HCII may be contacted regarding dues payments at SEIU HCII Member Resource Center 2229 S Halsted St, Chicago, IL 60608, mrc@seiuhcil.org, or 866-933-7348. I acknowledge that failure to pay my dues on a timely basis may affect my membership standing in the Union, as set forth in the SEIU HCII Constitution and Bylaws.

Contributions or gifts to HCII are not tax deductible as charitable contributions.

I want to hold politicians accountable to working families, and I know we can only do that if we stand together. I agree to make an automatic contribution each pay period to the SEIU Committee on Political Education (“SEIU COPE”) to build a strong voice for working families.

Each bi-weekly pay period I will contribute: (choose one)

I authorize Service Employees International Union Healthcare Illinois & Indiana and its successors and assigns (collectively “SEIU HCII”) to bill my credit card or debit card account, make withdrawals from my bank account, or charge any other payment method I provide in the amount of my SEIU COPE contribution, in addition to and in accordance with the authorization I have provided for direct payment of dues. I agree that these withdrawals may be made electronically. This authorization shall remain in effect until I revoke my authorization by emailing directpayrevocation@seiuhcil.org or any other permissible method.

This authorization is made voluntarily based on my specific understanding that: 1) I am not required to sign this form or make SEIU COPE contributions as a condition of my employment by my employer or membership in the union; 2) I may refuse to contribute without any reprisal; 3) Only union members and executive/administrative staff who are U.S. Citizens or lawful permanent residents are eligible to contribute to SEIU COPE; 4) The amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer; 5) SEIU COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state, and local elections.

Contributions to SEIU COPE are not tax deductible as charitable contributions.