SEIU Healthcare – United for Quality Care

New Membership Form

By joining together in a union, SEIU Healthcare 1199NW members speak with a united voice for quality healthcare and good jobs.

Be a part of the movement for quality care for our community. Fill out this form to join.

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First Name*
Last Name*
Email*
Cell Phone*
Hospital/Clinic/Agency*
Today's Date*
‡ 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.
Address*
Street Address Address Line 2 City State ZIP Code
Healthcare Workers' Support Agreement
I support healthcare workers’ effort to unite and advocate for quality healthcare and good careers. I hereby request and voluntarily accept membership in Service Employees International Union Healthcare 1199NW and authorize SEIU Healthcare 1199NW as my exclusive representative in collective bargaining with my employer.*
- Yes, I authorize the above.
Signature Verification 1*
Employer Deduction Agreement
I hereby request and voluntarily authorize my employers to deduct from my wages and to pay SEIU Healthcare 1199NW any initiation fee (unless not allowed by law or if employed prior to the signing of an initial collective bargaining agreement) and an amount equal to the regular monthly dues or fees uniformly applicable to members of SEIU Healthcare 1199NW. This authorization is granted for all of my Employers who have a Collective Bargaining relationship with SEIU Healthcare 1199NW. This authorization shall remain in effect and be irrevocable for a period of one year or until the termination of the collective bargaining agreement between my employer and SEIU Healthcare 1199NW, whichever occurs sooner. If I have a break in employment with all Employers that have a Collective Bargaining relationship with SEIU Healthcare 1199NW and resume employment with such an Employer within twelve (12) months, this authorization shall remain in effect. This authorization shall remain in effect and shall be irrevocable unless I revoke it by sending written notice via U.S. mail to both the employer and SEIU during the period not less than thirty (30) days and not more than forty-five (45) days before the annual anniversary date of this agreement or the date of termination of the applicable contract between the employers and SEIU, whichever occurs sooner. 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.*
- Yes, I authorize the above.
Signature Verification 2*

*Dues are 1.8 percent of your pay, with a cap of $90/month.

Step 1 of 2

Healthcare Workers' Support Agreement

Employer Deduction Agreement

New Membership Form