1392app

Laborers' Local 1392 Membership Application

Name*

First Name

Middle Initial

Last Name

Address*

City*

State*

Zip*

Phone 1*

(###) ###-####

Phone 2

(###) ###-####

SSN*

No Dashes

Email*

Confirm Email*

Date of Birth*

Place of Birth

Registered Voter

Yes No

EEOC Classifications - The following questions are asked solely for the purpose of meeting federal record keeping required by affirmative action. This hiring hall is administered without reguard to race, color, religion, sex, martial status, sexual orientation, national origin, disablility, age or veteran status, and in accordance with Federal, State and local laws.

Gender

Married?

Yes No

Are You a US Citizen?

Yes No

Are You a Veteran

Yes No

Ethnicity / Race

Employment History - List all construction/environmental employers for the previous 4 years. Begin with the most recent. Include all employers union and non-union.

Select How much Experience you have working in the trade ( Union and Non-Union)

More than 4 years Between 2 and 4 years Less than 2 years

Past Employment

1. Most Recent Employment - Include Employer, Job location, Dates Employed, & Phone

2. Include Employer, Job location, Dates Employed, & Phone

3. Include Employer, Job location, Dates Employed, & Phone

4. Include Employer, Job location, Dates Employed, & Phone

Skills and Certifications - Please select all Skills you are cabable of and or have performed in the past and for wich you would like to be coinsidered for work. Select all CERTIFICATIONS you have licenses for and when they expire.

Skills

Certification - Requires valid certificate or licence

Radworker II Hazardous Waste Hazardous Waste Supervisor Asbestos Abatement Asbestos Abatement Supervisor State Asbestos License Lead Abatement

Security Clearance

L Cleared Q Cleared

Select all Areas you are willing accept construction work.

Are you willing to accept a Market/Work Recovery job at a lessor wage

Yes No

Requirements to become a member in good standing with Local #1392

One time Initiation for book $600
-As long as you are working, a minimum of $50 a week is due to be paid at the local until the $600 book is paid in full.

Monthly Dues $40
-Upon receiving 2nd check a minimum of $180 required out of pocket. ($100 towards books and $80 for the 1st and 2nd months dues)

Select to Acknowledge

I fully understand the above stated expectations:

Acknowledgement Signature*

Enter Your Name here as Electronic Signature

Date*

Dues Checkoff Authorization

Local Union 1392 Affiliated with the Laborer’s International Union of North America, AFL-CIO
I do hereby assign to Local Union No. 1392 Laborers’ International Union of North America, AFL-CIO, such amounts from my wages as shall be required to pay an amount equivalent to the initiation fees, readmission fees, and membership dues of the Local Union as may be established for its members from time to time. My Employer, including my present Employer and any future Employer, is hereby authorized to deduct amounts from my wages and pay the same to the Local Union and/or it’s authorized representatives, in accordance with e the collective bargaining agreement in existence between the Union and my Employer.
This authorization shall become operative upon the effective date of each collective bargaining agreement entered into between the Union and my Employer.
This authorization shall be irrevocable for a period of (1) one year, or until termination of the collective bargaining agreement in existence between my Employer and the Union, whichever occurs sooner; and I agree and direct that this authorization shall be automatically renewed and shall be automatically renewed and shall be irrevocable for successive periods of one (1) year each, or for the period of any subsequent agreement between my Employer and the Local Union not more than twenty (20) days and not less than ten (10) days prior to the expiration of each period of one (1) year, or each applicable collective bargaining agreement between my Employer and the Union, whichever occurs sooner. For the effective period of this checkoff authorization and assignment, and to the extent permitted by law, I hereby waive any right I may have to resign my union membership. Furthermore, this checkoff authorization shall continue in accordance with the above renewal and revocation provisions irrespective of my membership in the Union.
Union dues and fees are not tax deductible as charitable contributions for Federal income tax purposes. However, they may be tax deductible under other provisions of the Internal Revenue Code. For example, they may be tax deductible as an “unreimbursed employee expense”, one of the miscellaneous job expenses that are deductible on Form 1040, Schedule A, “itemized deductions.” They may also be tax deductible as ordinary and necessary business expense.

Select to Authorize

I Grant My Authization for Dues Checkoff

Authorization Signature*

Enter Your Name here as Electronic Signature

Date*

Laborers' Code of Performance Acknowledgement

The goal of the Code of Performance is to ensure that our memberships meet the highest standards in our industries. Our aim is to deliver craftsmanship that exceeds the expectations of our contractors and their customers. We want to create and maintain a work force that makes contractors want to be Union and owners want to build Union.

Meeting these goals requires that members understand and incorporate these values in their day to day performance. Accordingly, as a member of the Laborers’ International Union of North America I agree to:

• Acquire the necessary skills though apprenticeship and/or training programs.
• Report promptly upon referral to a job and show up for work on time, ready, willing and able to work.
• Be aware of and follow the Local Union’s job referral rules
• Avoid excessive absenteeism and excessive tardiness
• Follow directions from supervisors
• Do not be insubordinate
• Give a fairs day work
• Treat the Employer’s and the customer’s tools and property and those of fellow workers with respect
• Avoid disruptions on the job by using the established procedures to resolve disputes
• Understand and use safe practices and safety equipment.

Select to Acknowledge

I acknowledge this responsibility and pledge my word to do the same and acknowledge that I have received, read and understand my Laborers’ Code of Performance.

Acknowledgement Signature*

Enter Your Name here as Electronic Signature

Date*

EMPLOYEE AUTHORIZATION OF PAYROLL DEDUCTIONS FOR KENTUCKY LABORERS’ POLITICAL LEAGUE

AND LABORERS' INTERNATIONAL UNION OF NORTH AMERICA PAC

I Authorize and direct each and every employer signatory to an agreement with the Kentucky Laborers’ District Council, Laborers’ Local Unions 189, 576, 1214, 1392 or 1445, the Laborers’ International Union of North America, or any of their affiliates or successors, to deduct from each of my paychecks the sum of five cents ($.05) per paid hour, and of that sum to remit three cents ($.03) per paid hour to the Kentucky Laborers Political League (“KY LPL”) and two ($.02) cents per paid hour to the Laborers’ International Union of North American Pac (“LIUNA PAC”). I understand that this is a voluntary contribution and I have the right to refuse to contribute without reprisal; contributing is not a condition of either membership in the Union or employment with my employer; and KY LPL and LIUNA PAC each will use the money it receives to make political expenditures and contributions in connection with federal, state, and local elections.

I also understand that the listed amounts above and any other guideline amounts are merely suggestions, and I will not be favored or disadvantaged because of the amount of my contribution or my decision not to contribute. I further understand that, due to the substantial number of employers signatory to the collective bargaining agreement and members’ frequent changes of employer in the construction industry, it is administratively infeasible for employers to agree to and implement variable payroll deduction amounts for KY LPL and LIUNA PAC contributions, and that if I wish to contribute more or less than the suggested amounts I may do so through alternative means with the Unions’ full assistance by contacting the Kentucky Laborers’ District Council at the address or phone number listed below (or any successor address or phone number).

Select to Authorize

I Grant My Authization for KY LPL & LIUNA PAC I do not Grant Authorization

Authorization Signature*

Enter Your Name here as Electronic Signature

Date*

Contributions to KY LPL and LIUNA PAC are not deductible as charitable contributions for federal income tax purposes. Only US Citizens or lawful permanent US residents are eligible to contribute. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions to LIUNA PAC exceed $200 in a calendar year.

Certification of this Application

I CERTIFY THAT ALL OF THE INFORMATION SUBMITTED BY ME ON THIS FORM IS ACCURATE AND COMPLETE, AND I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO UPDATE AND OTHERWISE KEEP CURRENT THE INFORMATION ON THIS FORM. I ALSO CERTIFY THAT I AM CURRENTLY PHYSICALLY ABLE TO PERFORM THE TASK OF THE SKILLS I HAVE SELECTED ABOVE.