Member Application

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Member Application

Please complete the following form to join over 15,000 healthcare workers, janitors, and security officers who make Oregon and Washington a great place to work and live.
Your information
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
Personal Email
example@example.com
Stay Informed. By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.

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* By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.
Work information
Employer*
Facility/Work Location
Department/Unit
Job Title*
Date of Hire

MonthDayYear
Date
Employee #
Work Email
example@example.com
Primary Language Spoken*
Membership commitment*

YES! I commit to being an active member with SEIU Local 49 and fighting for a strong contract now and in the future.
Sign here to commit*

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Automatic Dues Deduction/Checkoff Authorization: I hereby request and voluntarily authorize my employer to deduct from my earnings and to pay over to SEIU an amount equal to the regular monthly dues* uniformly applicable to members of SEIU. This authorization is irrevocable for a period of one year from the date of execution and from year to year thereafter unless I send, via U.S. mail, signed written notice to SEIU of my desire to revoke authorization not less than thirty (30) and not more than forty-five (45) days prior to the end of the annual period from the date of this execution or the termination of the applicable contract between my employer and my Union, whichever occurs first. This authorization shall be automatically renewed as an irrevocable check-off from year to year unless I revoke it in writing during the window period, even if I have resigned my membership in SEIU. Sign here to authorize. *

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* Contributions or gifts to SEIU are not tax deductible as charitable contributions. However, they may be tax deductible as ordinary and necessary business expenses.
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Member Application

Your information

Work information