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 _____________________________________________________________ Mail completed Form with your check to: Georgia AFL-CIO 501 Pulliam St., S.W. Suite 549 Atlanta, Ga. 30312 To email us: Click Phone 404.525.2793 Fax 404.525.5983 ____________________________________________________________________
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