Membership Card

Application for Membership and Authorization for Dues Deduction

First Name

Middle Initial

Last Name

Street Address

Apartment, Suite, etc.

City

State

ZIP/Postal Code

SSN (last four digits)

Retirement Date

Agency from which retired

Department

Location

Check here if surviving beneficiary of the retiree.

Beneficiary Information

First Name

Middle Initial

Last Name

Personal Email

Telephone

Authorization

I hereby authorize the Public Employees' Retirement System of Nevada (PERS) to deduct $5.00 each month, the amount certified by the Retiree Chapter as the current rate of dues. This deduction is to be turned over to Nevada Retirees Chapter 4041, AFSCME.

Signature

My electronic signature is a binding and valid signature. By signing here I agree to all of the terms and conditions set out in this authorization, which apply to my membership, dues payments and, if applicable, PEOPLE payments.