Florida Carpenter Regional Council

United Brotherhood of Carpenters and Joiners of America

Membership Application

Local/Affiliate Address 1

Legal First Name Address 2

Legal Middle Name City

Legal Last Name State/Province

Suffix Zip/Postal

Nickname Country

SSN/SIN Cell Phone ☐ Primary*

Date of Birth Home Phone ☐ Primary*

(MM/DD/YYYY) Other Phone ☐ Primary*

Email *Only select one phone number as the primary.

☐ Applicant Are you a Veteran? ☐ Yes ☐ No
☐ Pre-Apprentice
Classification
☐ Apprentice Were you a prior UBC member? ☐ Yes ☐ No
☐ Member/Journeyman If yes, enter the prior Local
☐ Carpenter ☐ Local Government
☐ Drywall Application ☐ Millwright
Craft ☐ Floor Layer ☐ Piledriver
☐ Industrial ☐ Scaffold
☐ Interior Systems ☐ Other ____________________
Gender Race

Obligation
I do, of my own free will and accord, solemnly and sincerely promise – on my sacred honor – that I will never reveal – by word or deed –
any of the business of this United Brotherhood – unless legally authorized to do so. I promise to abide by the Constitution and Laws – and
the will of the majority – observe the Bylaws and Trade Rules and that I will use every honorable means – to procure employment for
brother and sister members. I agree that I will ask for the Union label – and purchase union-made goods – and employ only union labor –
when same can be had. And I further affirm and declare – that I am not now affiliated with – and never will join or give aid – comfort – or
support to any organization that tries to disrupt the United Brotherhood of Carpenters and Joiners of America or any of its affiliates. I pledge
myself to be obedient to authority – orderly in the meetings – respectful in words and actions – and charitable in judgement of my brother
and sister members. To all of this I promise and pledge my most sacred word and honor as long as I remain a member of this Brotherhood.

Being admitted to membership, I agree to be bound by the above Obligation of the United Brotherhood of Carpenters and Joiners of
America, which I have read. I further agree that if it is found at any time that I have made false statements of any kind on this application
that my membership shall be declared void and all monies paid by me shall be forfeited.

Signature of Applicant Date (MM/DD/YYYY)

This application must be signed, dated, and submitted by the applicant after being fully completed.

ATTENTION APPLICANTS - Please click here for the UBC Welcome Kit for more information regarding membership in the UBC,
including legal notifications regarding Beck objector rights for members in the US in non-right-to-work states.

For Office Use Only:

Initiation Date Initiation Fee Paid Tax Schedule UBC ID

Date to Journeyman Supplemental Dues ☐Yes ☐ No Authorized Collective Bargaining ☐ Yes ☐ No

CLIC Donation ☐ Yes ☐ No (Voluntary) Political Affiliation

FLCRC application 12/22

 Authorization for Representation

I desire to be represented by and hereby authorize the Florida Carpenters Regional Council or its successor to be my
collective bargaining agent in matters of rates of pay, wages, fringe benefits, hours of employment, and other working
conditions. This authorization shall apply to the employer by whom I am employed on this date and all other employers by
whom I may become employed after this date.

Job Dispatch System

I am aware that the Union utilizes an online job dispatch system and that it is my responsibility to sign up for this system
and keep my information updated regularly. Web address www.flcrc.org/job-dispatch-system

Drug Screening

I am aware that I may be subject to Drug Testing and that I will be responsible for the cost of a positive test result.

Full Name (Printed) Date (MM/DD/YYYY)

Signature Witness Signature

FLCRC application 12/22

 FLORIDA CARPENTERS REGIONAL COUNCIL

DUES CHECK OFF AND AUTHORIZATION

I hereby voluntarily authorize and direct all my employers to deduct from my compensation, and to forward to the Florida
Carpenters Regional Council (hereinafter “FLCRC”), all required dues or assessments, including supplemental as set forth
by the FLCRC, and working dues in the sum of four and one-half percent (4.5%), or as set forth in any collective bargaining
agreement which applies to me. Such supplemental and working dues shall be based on my gross earnings.

I fully understand that this authorization for supplemental or working dues is not conditioned on my membership or non-
membership in the Florida Carpenters Regional Council.

By checking this box ☐ I authorize five cents ($.05) per hour, from the deducted amount, to the Florida Carpenters Regional
Council Committee of Continuous Existence or its successor as my member contributions.

This authorization shall be irrevocable for a period of one (1) year from the date hereof signed. This authorization shall
automatically renew itself and be irrevocable for successive annual periods unless I give written notice to the Florida
Carpenters Regional Council within the fifteen (15) day period following the expiration of any such annual period or, with
respect to any employer having a collective bargaining agreement, within the fifteen (15) day period following the
termination date of any such collective bargaining agreement.

SIGNED:

___________________________________________________________
Signature

___________________________________________________________
Print Name

UBC#______________________________________________________

Local Union#________________________________________________

Date: ______________________________________________________

FLCRC application 12/22

Additional New Member Information

Emergency Contact Name: __________________________________________ Phone: _____________________________________

Have you ever served in Armed Forces? Yes No

If yes, when (dates of service): __________________________________________________________________________________

Have you ever held Union Membership? Yes No

If yes, where: ________________________________________________________________________________________________

Have you ever been convicted of a felony? Yes No

If yes, please explain (we ask this because some job sites prohibit convicted felons):

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Education

High School attended: _________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Dates attended beginning: _________________________________ to ___________________________________________________

Did you graduate? Yes No

If No, do you have an equivalent? Yes No

Have you attended College or a Trade School? Yes No

School attended: ______________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Dates attended beginning: _________________________________ to ___________________________________________________

Did you graduate? Yes No

If yes, Degree obtained: ________________________________________________________________________________________

Additional College or a Trade School?

School attended: ______________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Dates attended beginning: _________________________________ to ___________________________________________________

Did you graduate? Yes No

If yes, Degree obtained? _______________________________________________________________________________________

FLCRC application 12/22

Employment History

Are you currently employed? Yes No

Current or most recent employer

Name: ______________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Phone: ______________________________ Supervisor’s Name: _______________________________________________________

May we contact for reference? Yes No

Work Performed: _____________________________________________________________________________________________

____________________________________________________________________________________________________________

Starting Date: _______________________________ Ending Date: _____________________________________________________

Wage Rate: __________________________________________________________________________________________________

Reason for leaving (if no longer employed): ________________________________________________________________________

____________________________________________________________________________________________________________

Former Employer

Name: ______________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Phone: ______________________________ Supervisor’s Name: _______________________________________________________

May we contact for reference? Yes No

Work Performed: _____________________________________________________________________________________________

____________________________________________________________________________________________________________

Reason for leaving: ___________________________________________________________________________________________

____________________________________________________________________________________________________________

Office Use Only

Reviewed by: ___________________________________________________ Date: ________________________________________

FLCRC application 12/22