Application for Affiliation with the Georgia AFL-CIO

Date ______/____/_______________

We wish to affiliate our organization with the Georgia State AFL-CIO by paying the

prescribed amount of 75 cents per member per month. Enclosed is our check for the

amount of $ ________ to pay Per Capita for ________members for the period

beginning ______/_______ through______/______ .

 ___________________________________________________/________________

^{Your Union Name and Local Number}  

^{______________________________________________________________________________________________} 

 ^{Street Address of our Organization} 

______________________________________________________________________________

^{City & State Zip Code}

^{Phone Number Fax Number}

____________________________________________________________________

^{Name & Title Officer to which Correspondence should be addressed}

 ________________________________________________________________________________

^{Street Address, P.O. Box or Route #}

________________________________________________________________________________

^{City, State & Zip Code}

Phone Number ______________________________________________________

Fax Number __________________________________________________________

E Mail address _____________________________________________________________

____________________________________________________________________