Membership Application

Member Information
I hereby tender my application for membership in the California Correctional Supervisors Organization (CCSO), and authorize the State Controller to deduct from my salary and wages, the amount specified now or in the future for membership dues, and any benefit program for which I have applied, which is sponsored by the above named Organization, for the purpose of negotiating with my employer on my behalf on all matters affecting my employment relations. As a condition of membership in CCSO, I agree to abide by the Constitution and Bylaws of CCSO, and faithfully carry out my obligations under the same. Dues are payable in monthly installments, due the first day of each month.

NOTE: CCSO Bylaw XII, Sec. 9 states, in part: “...the Organization does not incur any duty to represent any employee who joins the Organization after circumstances occur that prompt either a punitive action against said employee or a grievance from said employee...”
A percentage of your membership dues will be used for political action.
- Check here if you oppose
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Cell
Rank/Title*
Employed at Institution*
Birth Date*
MM slash DD slash YYYY
Gender*
- Male
- Female
This authorization will remain in effect until canceled by the Organization, or at my written request, subject to the provisions of any agreement in effect between the State of California and CCSO, that apply to my classification. I understand that termination of my membership will cancel all deductions made under this authorization.
Signature*
Date*
MM slash DD slash YYYY
Beneficiary Information
CCSO member has a $5,000 death benefit, effective, once beneficiary is designated below on this card. The beneficiary must be 18 years of age. A minor, must have a designated co-beneficiary listed. Family member must contact the CCSOoffice within 60 days after member’s death occurs.
Beneficiary Name
First Last
Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Member
Beneficiary Phone
Contingent Beneficiary Name
First Last
Contingent Beneficiary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contingent Beneficiary Phone
Contingent Beneficiary Relationship
Comments
This field is for validation purposes and should be left unchanged.

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