PEF Membership Application Page 1 of 1
TO BECOME A PEF MEMBER: Print out this application and mail it to Public
Employees Federation, Membership Benefits Program, PO Box 12414, Albany, NY 12212
Please complete the following information (if possible):
Name of Local PEF Division: _______________________________
PEF Division Number: ____________________________________
Do you want to be active in PEF? __ Yes __ No
Have you received orientation by PEF? __ Yes __No: Date: _______
Your PEF Steward’s Name: ________________________________
Have you served in the U.S. Military ___ Yes __No
If yes, Date of Service _____________________________
Please send me information on the following Membership Benefits:
__ Life Insurance __ Automobile Insurance
__ Group Disability Insurance __ Driver Safety Courses
__ PEF Legal Plan __ Homeowners/Tenants Insurance
New York State Public Employees Federation, AFL-CIO
DUES PAYROLL DEDUCTION AUTHORIZATION
Last Name First Name Middle Initial Social Security No.
Street Address City State Zip County Home Telephone No.
E-Mail Address (Home) E-Mail Address (Work)
Job Title Agency/Dept. Agency Code Payroll Item No.
Work Location (Address) Work Telephone No. PEF Division No.
The Comptroller of the State of New York:
Pursuant to Section 6a of the State Finance Law, I hereby authorize you to deduct from my salary on a bi-weekly the necessary amount to cover
membership dues payable on my behalf to NEW YORK STATE PUBLIC EMPLOYEES FEDERATION, AFL-CIO. You are further authorized to make
any necessary changes in the amount of such dues or insurance premiums. This authorization shall remain in effect until revoked by me by written notice
to you by certified mail or until otherwise revoked pursuant to law.
Date _________________ Signature of Employee ___________________________________________