I hereby make application for membership in the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION and affirm that the statements made 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 FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION to represent me for the purposes of collective bargaining and handling of grievances, either directly or through such local union as it may duly designate.

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By providing your E-MAIL you are authorizing UFCW Local 1000 to communicate via electronic mail. By agreeing to accept email communication, I understand that I am also authorizing UFCW Local 1000 to retain my email address in its databases so that it may send me future communications. I acknowledge and understand that email messages sent to me are not encrypted and travel over the Internet, resulting in a risk that any email will be intercepted and read by third parties to whom the e-mail is not directed. I hereby assume the foregoing risk.

I hereby authorize the United Food & Commercial Workers Local 1000 to represent me for the purpose of collective bargaining with respect to wages, hours and all working conditions. My employer is hereby authorized and directed to deduct from my wages, commencing with the next payroll period, an amount equal to union dues, initiation fees, and assessments as shall be certified by the President of Local 1000 of the United Food & Commercial Workers International Union, AFL_CIO, and remit same to said President. This authorization and assignment is voluntarily made in consideration for the cost of representation and collective bargaining and other activities undertaken by the Union and is not contingent upon my present or future membership in the Union. This Check-off authorization and Agreement shall be irrevocable for a period of one year from the date of execution or until the termination date of the agreement between the Employer and Local 1000, whichever occurs sooner, and from year to year thereafter, unless not less than ten (10) days and not more than (20) days prior to the end of any subsequent yearly period I give the Employer and the Union individually written notice, by mail, of revocation bearing my signature thereto. The President of Local 1000 is authorized to deposit this authorization with any Employer under contract with Local 1000 and is further authorized to transfer this authorization to any other Employer with Local 1000 in the event that I should change employment. This authorization shall likewise be fully enforceable and effective in the event I leave employment with any employer under contract with United Food & Commercial Workers Local 1000 and at a later time re-obtain employment with that same employer or any other Employer under contract with Local 1000, regardless of the length of time between termination and reemployment. In the event I am promoted or transferred out of the bargaining unit I understand that dues will no longer be deducted on my behalf. I acknowledge my responsibility to ensure dues are no longer deducted when my representation has ceased. However if dues are inadvertently deducted and I am owed back dues, UFCW Local 1000 will reimburse those dues for a period not to exceed 90 days.

I hereby authorize my Employer to deduct the sum of $1.00 per week from my paycheck and $5.00 annually the first pay period of July. Such amount to be transmitted to the UFCW International Active Ballot Club at such time and in such manner as may be agreed upon by my Employer and Local Union. I understand that this authorization is voluntarily made and that the amount suggested as a contribution is a guideline and that I may contribute more or less than this amount by any lawful means, other than this checkoff, or may refuse to contribute and that the making of payments to the UFCW Active Ballot Club is not a condition of membership in the Union or of employment with employer and that I have a right to refuse to sign this authorization and not to contribute to the UFCW ABC without reprisal. I also understand that my contribution will be used for political purposes, including the support of candidates for federal, state and local office. I expressly reserve the right to revoke at any time this authorization in writing.

I grant permission to UFCW Local 1000 and UFCW International Union (“UFCW”) to use my name, image, likeness, voice, and provided information in publications, handbills, videos, websites, and other communications the UFCW publishes, produces or sponsors. I also release any and all rights to such information and likeness to the UFCW.