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 ___________________________________________