UEMPA Member Application

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.Personal (non-work) email address
example@example.com
3
Address* This field is required.Home or Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Mobile / Cell Phone Number* This field is required.
Area Code
Phone Number
5
Alternate Phone / Home Phone
Area Code
Phone Number
6
Date of Birth* This field is required.
Date
Year
Month
Day
7
Gender
Please Select
Please Select
Male
Female
N/A
8
Bargaining Unit Employer* This field is required.
American Medical Response (Central Arizona)
American Medical Response (Southern Arizona)
Maricopa Ambulance, LLC
Life Line (Central Arizona)
Arizona Ambulance- Cochise County
9
Job PositionCurrent position at time of application.
Emergency Medical Technician
Paramedic
Registered Nurse
Dispatcher
VST
EMR
Call Taker
10
Were you hired as part of an EMT Academy?Earn While you Learn or similar.
YESNO
11
Employment StatusEmployment Status at time of application.
Full Time
Part Time
12
Employee NumberEnter employee number. Leave blank if unknown.
13
Did you transfer from another division of the Company?This could be from another state, bargaining unit or department.
YESNO
14
IAFF Union Membership* This field is required.I hereby make application for membership in the INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS (IAFF) union and affirm that the statements herein are true, and I agree that all moneys, paid by me shall be forfeited and my membership declared void if they are not true. I authorize the UNITED EMERGENCY MEDICAL PROFESSIONALS OF ARIZONA (IAFF LOCAL I-60) to represent me for the purposes of collective bargaining and handling of grievance. I understand that my membership may be cancelled at any time by providing a thirty (30) day notice, in writing, to the union's secretary.
YESNO
15
Payroll Deduction Authorization* This field is required.I hereby authorize and direct the deduction from my wages, commencing with the next payroll period, an amount equivalent to dues and fees as shall be certified by the Secretary-Treasurer of the United Emergency Medical Professionals of Arizona (a/k/a International Association of Fire Fighters, Local I-60), and remit funds to the Union. This authorization and assignment is voluntarily made in consideration for the cost of representation and collective bargaining and is not contingent upon my present or future membership in the Union. This authorization and assignment shall be irrevocable for a period of one (1) year from the date of execution or until the termination date of the agreement between the Employer and the Union, whichever occurs sooner, and from year to year thereafter, unless not than thirty (30) days and not more than forty-five (45) days prior to the end of any subsequent yearly period or termination date of the agreement between the employer and the Union, I give the Union written notice of revocation. The Secretary-Treasurer is authorized to provide this authorization with any Employer under contract with the Union and is further authorized to transfer this authorization to any otherEmployer under contract with the Union in the even I should change employment.
YESNO
16
UEMPA Charities DonationUEMPA Charities, an organization separate from the union, is a 501(c)3 non-profit with public charity status. Its mission is to support EMS professionals and their families in times of need.
$3.00 per pay period
I do not wish to donate
$3.00 per pay period
$5.00 per pay period
$10.00 per pay period
$15.00 per pay period
17
Charity Payroll Deduction Authorization* This field is required.I hereby authorize and direct the deduction from my wages, commencing with the next payroll period in the amount specified in this form.
YESNO
18
Signature
Clear
19
Please verify that you are human* This field is required.
Should be Empty: