Intent Card & Membership Form Please enable JavaScript in your browser to complete this form.Layout If you do not wish to join any union at this time but want a choice in who represents you in an upcoming election, please complete the intent card listed below. If you wish to join FWC please complete the application at the bottom of this page. If you decide to join, your membership application willserve as your intent to have FWC represent you in collective bargaining.Undersign *I, the undersigned, authorize Fairfax Workers Coalition, (FWC) to represent me as my exclusive bargaining agent with my employer, Fairfax County Government.NAME *FirstLastADDRESS:Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutPHONE *Agency (optional):EMAIL: *Job Title (optional):Fairfax Workers Coalition Authorization for Deduction of Dues Active County EmployeesApply for Membership *I, the undersigned, hereby apply for membership in the Fairfax Workers’ Coalition (FWC) as my duly authorized representative on matters relating to my workplace issues, pay, benefits, retirement and health care. Please consider this your authority to abide by the Constitution and By Laws of FWC.Authorize my Employer *I hereby authorize my employer, the Fairfax County government, to deduct from my earnings the current dues of $10 per pay period, only subject to change by an open membership vote in accordance with FWC’s Constitution and By Laws.NAME: *FirstLastAGENCY/FOCUS ID (last 4 of SS#) *MAILING ADDRESSAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutPHONE (HOME )PHONE (MOBILE ) *EMAIL ADDRESS: *LayoutSIGNATURE *Clear SignatureDATE: *WELCOME TO YOUR INDEPENDENT VOICE FOR FAIRFAX COUNTY WORKERS! FOR USE BY FFXWC OFFICIAL I hereby certify that the regular dues of this organization for the above named member are currently established at $10.00 biweekly. LayoutSIGNATURE AND TITLE OF AUTHORIZED UNION OFFICIALDATEPlease scan and email to fairfaxworkerscoalition@outlook.com or take picture and send to 703-401-3131Submit
