(For Payroll deduction purposes, AFSCME Local 4041 must have an original signature 
on the completed card, we cannot accept an emailed or faxed copy.)

AFSCME MEMBERSHIP APPLICATION
(Please print clearly)
Name: ______________________________________SS#______________________
Residential Address: _____________________________________________________
City: __________________________________ State: _________ Zip: _____________
Mailing Address: ________________________________________________________
City: _________________________________ State: _________ Zip: ______________
Home Email Address: ___________________________@________________
Home Phone: ______________________Work Phone: ________________________
Date of Hire with State:____/____/____ Employing Agency: _______________________
Department: ___________________________ Classification: _____________________
Registered Voter:    Y    N           Assembly District: ________ Senate District: _________
AFSCME Chapter: ______________________ Recruited By: ____________________

Date: _____/_____/______ Signature: _______________________________________

I understand that this application is for membership in the AFSCME Local 4041, and authorizes AFSCME
Local 4041 to represent me in matters pertaining to my employment with the State of Nevada.
This includes membership in the Political Information Committee, Inc.
I HEREBY AUTHORIZE  my employer to deduct from my salary the membership dues and benefit program payment
in effect at this time or as modified in the future. This authorization will remain in effect as outlined in NAC 281.260.