Union Membership Enrollment Form

Everett Coaches / Extracurricular Association

Name: __________________________ ____________________

Please Print Employee ID #

I hereby request membership in the Everett Coaches and Extracurricular

Association and authorize union membership dues to be withheld from my

salary each pay period and transmitted to the treasurer of the union. I agree that this authorization for payroll deduction shall be renewed each year thereafter unless written notice of revocation is given by me to the Everett Coaches and Extracurricular Association.

Signature: ____________________________ Date: ________________

Mailing Address: ___________________________________________

City: __________________________ State: ________ Zip: _________

Home Phone: ( ) ________________________

Cell Phone: ( ) ________________________

Work Phone: ( ) ________________________

Home e-mail: ____________________________

Work e-mail: ____________________________

Please send completed form to

Brian Sachse/Eisenhower Middle School