SAN DIEGO HOUSE STAFF ASSOCIATION (SDHSA) MEMBERSHIP APPLICATION
Please fill out the form below (note: certain are sections required), date and electronically SIGN IT and then click on the "Submit" surfboard at bottom. If you would like more information, please visit our website at www.sdhousestaff.org or contact the SDHSA: email@example.com
UCSD Employee ID # (If known)
Employee Status (Currently)
Appointment Start Date (Date on which you did or will formally commence employment as a member of the House Staff at UCSD)?
Contact Phone Number
Mailing Address (Optional)
Street Address Line 2
State / Province
Postal / Zip Code
I wish to be a member of the San Diego House Staff Association (SDHSA)
I, (the above-named person), elect to become a Member of the San Diego House Staff Association, A California Non-Profit Corporation (hereinafter the “Association”) and the California Public Employment Relations Board (PERB) certified Exclusive Labor Representative (Union) of the University of California, San Diego's ("UCSD" or the “Employer”) “House Staff” (Interns, Residents and Fellows). I appoint the Association as my exclusive collective bargaining representative and labor relations agent and authorize the Association to act on my behalf in all collective bargaining matters, including wages, benefits, and the terms and conditions of my employment with UCSD. I also authorize and direct said Employer to deduct from my wages an amount equal to Association’s Dues as authorized by the Association’s Board of Directors, and pay the same to the Association in accordance with the terms of the then current Collective Bargaining Agreement. Furthermore, I agree to abide by the Association’s then current Member’s Policies and Procedures. This authorization is voluntarily made in order to confirm my Membership with the Association and pay my fair share of the Association’s cost of representing me as indicated herein.
Date of Signature
Click or tap the box
Should be Empty: