TWU Local 525

Citrus Connection Organization Membership Authorization

(PERC FORM 2023-1.101, Incorporated in R. 60CC-1.101, Effective July 1, 2023)
Exemptions from this form are provided in section 447.301(1)(b)6., Florida Statutes, as amended by chapter 2023-35, section 1, Laws of Florida.
View Form Instructions

PART A – EMPLOYEE ORGANIZATION INFORMATION

NAME OF EMPLOYEE ORGANIZATION

PERC REGISTRATION NUMBER:

OR-

DATE OF LAST ORDER GRANTING REGISTRATION

INITIATION FEE

(if none, state zero)

DUES

(write amount in applicable blank)

WEEKLY

BIWEEKLY

MONTHLY

ANNUALLY

OFFICER/EMPLOYEE COMPENSATION

List the salaries, allowances, and other direct or indirect disbursements, exceeding $10,000.00 in the aggregate, paid by the employee organization and any affiliates to the five highest compensated individuals, as reported on the last PERC registration or renewal application. If fewer than five individuals are reported, indicate “N/A” on any remaining blank lines.

Name of Officer or Employee

Salary

Allowances

Other direct or indirect disbursements (incl. reimbursed expenses)

PART B – EMPLOYEE INFORMATION
***THE EMPLOYEE MUST PERSONALLY SIGN AND COMPLETE THE DATE OF SIGNATURE***

First Name *

Middle Name

Last Name *

NAME OF PUBLIC EMPLOYER

NAME OF AGENCY

If the Agency is the same as the Public Employer - check here

Yes

CLASS TITLE

CLASS CODE

If not applicable - check here

Yes

By my signature below, I represent that I desire to be a member of the above-named employee organization.

Signature of Employee *

Use your mouse, finger, or touch device to write your signature.

Date of Signature *

* Required Fields

(Application for Membership - Citrus Connection Employees Only)