New York State Public Employees Federation, AFL-CIO DUES PAYROLL

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					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 ___________________________________________




http://www.pefmembershipbenefits.org/join.html                                                                                                      5/29/2009