AUSTIN COMMUNITY COLLEGE A



ACC/AFT Local 6249 MEMBERSHIP APPLICATIONAustin Community College American Federation of TeachersAffiliated with TexasAFT, AFT, AFL-CIO3000 South I.H. 35, Suite 175, Austin, Texas, 78704, Phone 512-448-0130, Fax 512-448-0678, web: Name: ___________________________________________ E-Mail : ______________________________________________ Home Address: ___________________________________________ City: ____________________ Zip Code: ___________ Home Phone: ________________________ Work Phone: _________________ Cell Phone: _________________________ Date of Birth: ___________________________ Last 4 digits of SSN: _____________ Campus: ________________________ ? Opt in for text message alerts ACC Position (check one): ? Full-Time Faculty ? Adjunct Faculty ? Professional/Technical ? Classified ? Hourly ACC/AFT dues are based upon classes of membership defined in the national AFT constitution and by-laws. The dues levels are based upon your estimated current annual calendar year income. Please check your income category below & note the monthly amount associated with it.??? Less than $12,000 annual income ? Less than $25,000 annual income ? $25,000 or more annual income $17.83 monthly $22.71 monthly $38.75 monthly ($28.88 if Classified or Prof-Tech)BUILD A POWERFUL VOICE - JOIN COPEJoin our Committee on Political Education (COPE): Members are encouraged to make a voluntary contribution toCOPE. Help us support pro-employee candidates by making a regular monthly contribution. Changestarts with you! Let’s make a difference together. Your contribution will be added to your monthly dues amount.Make a monthly contribution: ? $1 ? $5 (recommended) ? $8 ? $10 ? Other $______________ Signature for COPE: ___________________________________ Date (COPE Authorization): _____________________This authorization is signed freely and voluntarily and not out of any fear of reprisal, and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used to make political contributions by Texas AFT COPE II and/or my local AFT affiliate’s COPE fund. The union may engage in joint fundraising efforts with the AFT and AFL-CIO. A voluntary COPE authorization may be revoked at any time by notifying Texas AFT and/or my local affiliate in writing of the desire to do so. Texas law prohibits AFT from contributing general dues dollars to political campaigns. Contribution or gifts made to any COPE fund are not deductible as charitable contributions for federal income tax purposes. Contributions cannot be reimbursed or paid by any other person or entity. Fill out the form below for dues bank draft or send annual dues check payable to “ACC/AFT”. Forward this form to ACC/AFT, 3000 S. IH 35, Suite 175, Austin, TX 78704 or to “AFT” at RGC.ELECTRONIC DUES PAYMENT: I authorize the above named entity to draft my bank account for the amount equal to my union dues. The monthly dues amount may change if required by local, state or national constitutions. I authorize my bank to adjust my monthly payment when notified by the named entity listed above. This authorization remains in effect until terminated in writing by me. These deductions will continue for this school year and future years, including any increases in dues, until terminated by me in writing. Bank Name: _______________________________________ Account type: ? CHECKING ? SAVINGS Bank Routing #: ______________________________ Bank Account #: _________________________________ SIGNATURE: ________________________________________________DATE: __________________________ This material is not intended to solicit members of the National Education Association or any of its affiliates. ................
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