NAPE Member Card NAPE Membership Card Registration Form Please complete the application form accurately and to the best of your ability. If you have questions, please contact Betty or Mandy in Membership at firstname.lastname@example.org or email@example.com or by phone at 1.800.563.4442 Personal InformationYour First NameYour Middle NameYour Last NameYour Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you updating your contact information?* Yes No Have you completed a member registration card before (online or paper version)?* Yes No Are you trying to change/update your last/family/married name?* Yes No If yes, please provide your current/former full name (so we can find it in our system and adjust accordingly)GenderMaleFemaleOtherYour 4 digit NAPE Local Number (if you know it)Please enter a number from 1000 to 9999.Contact InformationYour Home Address* Street Address Address Line 2 City Postal Code Your HOME phone numberYour WORK phone numberYour CELL phone numberYour PERSONAL email address Your WORK email address Employer InformationYour employer*Your work site (building/facility and address)Your job classification (i.e. Clerk II, LPN I, Home Support Worker, Correctional Officer, Social Worker I, etc.):*When did you start with this employer?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your current Job Status* Permanent, full-time Permanent, part-time Temporary, full-time Temporary, part-time (including call-in) Seasonal Consent and Confirmation* I agree that the information provided is accurate and to the following statement:"The information provided on this form is accurate and I hereby accept membership in the Newfoundland and Labrador Association of Public and Private Employees (hereafter: NAPE) and hereby authorize NAPE, its agents or representatives to represent me as the exclusive bargaining agent with my employer. I agree to abide by the By-laws and Constitution of NAPE, and I hereby authorize the Employer to release my employment-related information to NAPE."