• Application for CIR/SEIU Membership - UC Statewide

  • Welcome to the Committee of Interns and Residents/SEIU! CIR/SEIU negotiates for improved salaries, benefits, and working conditions for House Staff. It is run by and for House Staff. Your dues are the main source of support for CIR/SEIU activities.

  • CIR: (212) 356-8100  info@cirseiu.org  www.cirseiu.org 

  • Member Information

  • Hire Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • *By providing my phone number, I understand that CIR, SEIU, and their affiliates may contact me using automated calling technologies and/or text message me on my cellular phone on a periodic basis. CIR and SEIU will never charge for text message alerts. Carrier messages and data rates may apply to such alerts. Reply STOP to stop receiving messages. Reply HELP for more information.

  • Payroll Deduction Authorization

  • I recognize the need for a strong union and believe everyone represented by our union should pay their fair share to support our union’s activities. I hereby request and voluntarily authorize my employer, when and only when I am on its payroll, to deduct from my earnings and to pay over to CIR an amount equal to the regular weekly, bi-weekly, or monthly dues (1.6% of base pay) uniformly applicable to members of CIR, SEIU. This authorization shall remain in effect unless I revoke it by sending written notice via email or U.S. mail to the Committee of Interns and Residents, SEIU during the month of July of any year of my employment or within fifteen days before or after the termination of the applicable collective bargaining agreement between my employer or CIR. This authorization shall be automatically renewed from year to year unless I revoke it in writing during a window period, even if I have resigned my membership in CIR. If a court or governmental agency should find any provision of this card to be unenforceable, this shall not impair the validity or enforceability of the remaining language.

    This authorization is voluntary and is not a condition of my employment, and I can decline to agree to it without reprisal. I understand that all members benefit from everyone’s commitments because they help to build a strong union that is able to plan for the future.

    Dues, contributions, or gifts paid to CIR are not tax deductible as charitable contributions.

  • I recognize the need for a strong union and believe everyone represented by our union should pay their fair share to support our union’s activities. I hereby request and voluntarily authorize my employer, when and only when I am on its payroll, to deduct from my earnings and to pay over to San Diego House Staff Association/Committee of Interns and Residents (“SDHSA/CIR”) an amount equal to the regular weekly, bi-weekly, or monthly dues (1.6% of base pay). This authorization shall remain in effect unless I revoke it by sending written notice via email or U.S. mail to SDHSA/CIR during the month of July of any year of my employment or within fifteen days before or after the termination of the applicable collective bargaining agreement between my employer and SDHSA/CIR. This authorization shall be automatically renewed from year to year unless I revoke it in writing during a window period, even if I have resigned my membership in SDHSA/CIR. If a court or governmental agency should find any provision of this card to be unenforceable, this shall not impair the validity or enforceability of the remaining language.

    This authorization is voluntary and is not a condition of my employment, and I can decline to agree to it without reprisal. I understand that all members benefit from everyone’s commitments because they help to build a strong union that is able to plan for the future.

    Dues, contributions, or gifts paid to CIR are not tax deductible as charitable contributions.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please note you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature.

  • Membership Authorization

  • Yes, I want to join with my fellow employees and become a member of the Committee of Interns and Residents (“CIR”). I request and voluntarily accept membership in CIR. This means I will receive the benefits and abide by the obligations of membership set forth in the Constitutions and Bylaws of both CIR and the Service Employees International Union (“SEIU”). I authorize CIR to act as my representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer, and as my exclusive representative where authorized by law. My membership will be continuous unless I resign by providing notice to CIR by U.S. mail or email. I know that membership in CIR is voluntary and is not a condition of employment, and that I can decline to join without reprisal.

  • Yes, I want to join with my fellow employees and become a member of the San Diego House Staff Association which is an affiliate of the Committee of Interns and Residents (“SDHSA/CIR”). I request and voluntarily accept membership in SDHSA/CIR. This means I will receive the benefits and abide by the obligations of membership set forth in the current SDHSA Members Policies and Procedures, as well as those set forth in Constitutions and Bylaws of both CIR and the Service Employees International Union (“SEIU”). I authorize SDHSA/CIR to act as my representative in collective bargaining over wages, benefits, and other terms and conditions of employment with my employer, and as my exclusive representative where authorized by law. My membership will be continuous unless I resign by providing notice to SDHSA/CIR by U.S. mail or email. I know that membership in SDHSA/CIR is voluntary and is not a condition of employment, and that I can decline to join without reprisal.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please note you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature.

  • SEIU COPE (Committee on Political Education) Authorization

  • YES, I want to be an advocate for my patients. Sign me up to contribute to SEIU COPE

  • I hereby authorize my employer to deduct:

  • from my paycheck and transfer the funds as a voluntary contribution to SEIU COPE. I understand that: 1) I am not required to sign this form or make SEIU COPE contributions as a condition of my employment by my employer or membership in the union; 2) I may refuse to contribute without any reprisal; 3) Only union members and executive/administrative staff who are U.S. citizens or lawful permanent residents are eligible to contribute to SEIU COPE; 4) The amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer; 5) SEIU COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections. Contributions to the SEIU COPE are not deductible for federal income tax purposes. This authorization shall remain in effect until revoked in writing by me and sent to CIR/SEIU Healthcare Local 1957 or my hospital's payroll office.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please note you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature.

  • Should be Empty: