Full Name
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First Name
Middle Name
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Day
Year
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Mailing Address
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Street Address
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City
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Preferred Personal Phone Number
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Area Code
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Phone Type
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Preferred Personal E-mail
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I hereby apply for membership in the VSEA and authorize VSEA to represent me as the exclusive bargaining agent. I authorize payroll to deduct VSEA dues from my salary in the amount certified by VSEA in this and succeeding years of my employment and membership. I understand dues can be changed by the members of VSEA at their annual meeting. I under-stand this authorization may be revoked at any time with written notice to VSEA and Payroll Officer.
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I agree to the above statement and authorize VSEA to represent me as the exclusive bargaining agent.
Payroll:
(For VSC and VSHA employees only) I have also filled out my employer's appropriate Payroll Form.
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