Employee Number: Date Of Birth: Gender: Male Female Salutation: Mr Mrs Ms Miss

First Name: Middle Name: Surname:

Home Address:

Postcode: Home Phone: Mobile:

Email address: Repeat in uppercase:

Employer: Designation:

Workplace: Team/Department:

Work Address:

Work Postcode: Work Phone: Work Fax:

How many hours per week do you work? Are you: Permanent Casual Fixed Term Contractor Sub-Contractor Shift: Day Night

Are you interested in becoming a contact, activist or Union Rep? Yes No

Payment Method - Automatic Deduction from Credit Card

Deduction Frequency: Every 3 months Every 6 months Annually (10% discount) Card Type: Bankcard Mastercard Visa

Credit Card Number: Expiry Date:

Application Agreement

I hereby make application to be a member of the CEPU NSW Postal & Telecommunications Branch. If accepted, I agree to conform to the Union rules and any amendments thereof. Financial Obligation: Members are required to pay membership fees and levies (if any). CEPU may sue to recover unpaid monies Resignation: You may resign from the CEPU by written notice to the State Secretary. If you are no longer eligible to be a CEPU members, your resignation will take affect on the day the resignation is received, or on any later date specified in the resignation. Else, your resignation will take affect 14 days after the resignation is received or any later date specified in the resignation. You remain liable for any dues until resignation takes affect. Privacy Statement: CEPU is bound by the Privacy Act. Information is collected to enable CEPU to contact you about matters relating to your membership and to ensure that we have the necessary information to represent your employment and related interests. If you do NOT wish to receive any communications not related to the CEPU and your employment, please advise the Union Office. CEPU's privacy statement is available from the Union's website or by contact the Union Office.

Direct Debit Customer Authority

I authorise the CEPU NSW Communications Division to debit from my credit card the amount of my CEPU dues, and future dues as prescribed from time to time under the rules of the CEPU. This authorisation is to remain in force until revoked by CEPU or cancelled by me in writing.

I have read and understood the above Application Agreement and Direct Debit Customer Authority and wish to make application to become a member of the CEPU