NGO 2015 2016

(This All-In-One form covers SEIU Local 1000 Membership Cancellation, Non-Germane
Objector (NGO), and Fair Share Fee Challenger)

Todays Date
To SEIU Local 1000:

I am submitting this form to cancel my SEIU Local 1000 membership.

I am filing for Non-Germane Objector status under California Government Code:
Sections 3513-3515.
I object the use of my fees during the 2015-16 Fee Payer Year for activities not germane
to collective bargaining.

This request is submitted after the July 1st deadline due to (circle 1 or 2 or both):
1- Misrepresentation by an SEIU Representative:
2- As a Union Member, I have not been informed of my right/choice to apply for NGO status
which reduces my dues by 34%. Non-members are informed yearly of their choice. I feel it is
discriminatory not to enlighten me & ensure I understand my rights as a Member.

Signature
Print Your First & Last Name
Address: Street

Agency / Bargaining Unit

City

Zip Code

Last 4 digits of your SSN (for identification)

MAIL THIS FORM CERTIFIED RECEIPT TO:

SEIU LOCAL 1000 MEMBERSHIP/PROCESSING CENTER
1108 O Street, Ste 415, Sacramento, CA 95814