L.A. Care Health Plan Digital Authorization Card

"*" indicates required fields

I support working alongside my co-workers at L.A. Care Health Plan to create a stronger voice in decisions affecting our workplace, families, and future. My signature indicates that I desire to be represented by the Service Employees International Union (SEIU) Local 721 for the purpose of meeting and negotiating or meeting and conferring on wages, hours and other terms and conditions of employment. I understand this authorization card can be used by SEIU Local 721 to establish majority support among employees in the unit for which I am employed for a Public Employment Relations Board election and/or to obtain recognition as my exclusive collective bargaining representative.

Employee Information

First Name*

Middle Initial

Last Name*

Personal Email Address*

Please do not enter a work email

Cell Phone

By providing my cellular telephone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. To stop receiving messages, text STOP to 31996. Text HELP to 31996 for more information.

Home Phone

Home Address*

Street Address City Zip Code

Employer*

Department

If you work in a specific department please list it. If not please leave it blank.

Job Classification*

Shift

Employer Address

Street Address City Zip Code

Signature

YES, I UNDERSTAND AND AGREE TO THE TERMS ABOVE.*

Please check the box above to confirm

Electronic Signature*

BY CLICKING SUBMIT, YOU ACCEPT THAT YOUR PRINTED NAME, IP ADDRESS AND THE DATE AND TIME WILL BE USED AS YOUR DIGITAL SIGNATURE FOR THE PURPOSES OF THIS FORM.

Today's Date*