DISTRICT NO. 1-PCD, MEBA
DEEP-SEA APPLICATION CHECKLIST
FOR HEADQUARTERS USE ONLY
Applicant’s Name: ______________________________ SSN: ____________________
Last First M.I.
Port of application: _______________________ Date of application: _____________
Initial HQ Review By: _______________ Date: _________________
Application Checklist from Port Reviewed; all documents provided Member & Applicant Data Base Entry on ______________________
Effective Date of Application (If not above): ____________________
Application Book # __________________ Issued ________________
Group III Card Expires ______________ Issued _________________
One Year from Date of Application _________________________
One Year Follow Up to Initial Processing:
Review By: ___________________ Date _________________
Follow-up Verification Form Received _________________
First letter of recommendation Received _________________
Second letter of recommendation Received ________________
If Not, Reminder Sent to Applicant on ____________________
25 months from Date of Application _______________
25 Month Follow Up:
Review By: ___________________ Date __________________
All one year requirements met, 60 days, 2 recommendations If Not, 2d Reminder Sent to Applicant on _______________
Initiation Fee Remaining ______________
Reminder to complete initiation payment sent ________________
Completion of Requirements: Review by __________________
Initiation Paid on ________________ Dues through _____________
All one year requirements met, 60 days, 2 recommendations Forwarded for DIC Review on ___________ By ______________
DSA-00HQC 4/03
DISTRICT NO. 1-PCD, MEBA
DEEP-SEA APPLICATION CHECKLIST
TO BE COMPLETED BY AUTHORIZED UNION OFFICIAL
Applicant’s Name: ____________________________________________________
Last FirstM.I.
Applicant’s SSN: _______________________ Date of application: _____________
Port of application: __________________Union Official:______________________
Member & Applicant Data Sheet
Authorization and Application for Membership (4 pages)
Initiation Fee Agreement
Power of Attorney
Voluntary Relinquishment of Job Form
MEBA Vacation Plan Authorization
Obligation Form
Acknowledgement of Duties
Effective Date of Application Form (If applicable) _______________
Applicant Identification Form
I-9 Completed and Copy of Passport expires _______________
USCG License (copy front and back) : expires ___________
USCG License endorsed as: ______________________________
Copy of STCW expires _______________
Deep-Sea Applicant Information Fact Sheet (5 pages)
Copy of Merchant Mariner’s Document: expires ______________
Copy of current service fee receipt: from __________ to _________
MEBA Political Action Fund Authorization (optional)
MEBA Benefits Plans Form (3 pages)
Follow-up Verification Form supplied to applicant
Two letter of recommendation forms supplied to applicant
Copy of completed application forms supplied to applicant, Original completed application forms sent to HQ.
DSA-00UCL 4/03
Membership Affiliation: Deep Sea
AUTHORIZATION AND APPLICATION FOR MEMBERSHIP
To The Officers and Members of:
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
of the
NATIONAL MARINE ENGINEERS’
BENEFICIAL ASSOCIATION (AFL-CIO)
I hereby apply for membership in the District No. 1-PCD, MEBA (AFL-CIO).
I do hereby authorize and designate the union, District No. 1-PCD, MEBA (AFL- CIO) as my sole collective bargaining representative to represent me and, in my behalf, to negotiate and conclude all agreements as to wages, hours of labor, and other employment conditions.
It is understood that the Union has the absolute right to reject or terminate this Application at any time prior to my admission as a member into the Union. I also understand that in the event I voluntarily terminate my applicant status or I am dropped from applicant status due to non-payment of initiation or service fees, I shall not be entitled to any refund or reimbursement of such initiation or service fees.
I understand and agree that it shall be exclusively my obligation to notify the Union in writing when I have fulfilled the requirements for membership as set forth in the Constitution, By-Laws, Rules and Regulations of the Union, and any applicable Application Information Fact Sheet which are available upon request.
Pending my admission as a member into the Union, I shall be obligated to pay to the Union a service fee equal to what is being paid by members of their dues and I shall be entitled to exercise and enjoy only such rights and privileges (including shipping rights) as may be accorded to me under the outstanding Constitution, By-Laws, Rules, Regulations of the Union, and any applicable Application Information Fact Sheet.
It is further understood and agreed that the processing of my application for membership is subject to and conditioned upon the Constitution, By-Laws, Rules and Regulations of the Union and any applicable Application Information Fact Sheet covering such subject.
_____________________________________
(Print Name of Applicant)
______________________________________ |
_____________________ |
(Signature of Applicant) |
(Date) |
P. 1 of 4 |
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DSA-02AAM 4-03 |
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(Yes or No)
(use separate sheet if necessary):
(Yes or No)
I. PRIOR MEMBERSHIP
Have you ever previously made application for membership in District No. 1-PCD, MEBA or any other District of the National MEBA? _______________
If Yes:
Where ___________________________When ________________________________
(Branch)(Date of Application)
Membership _________ Rejected or Dropped __________ Withdrawn _____________
(Date)(Date)(Date)
If you are a former member/applicant, state which District or Subordinate Association. District No. _________Date Joined ________________Date Separated ______________
Status of Separation:
Suspended _________Dropped ___________ Expelled _________ Withdrew ________
(Date)(Date)(Date)(Date)
Have you ever been found guilty of charges or suspended from the shipping or night list in this Union? _____________. If Yes: Where: ______________ When: ____________
(Yes or No)(Branch)(Date)
Reason _________________________________________________________________
_______________________________________________________________________
II. PRESENT/PRIOR EMPLOYMENT:
Have you ever been employed as a licensed marine officer on U.S. flag vessels not working under a contract to District No. 1 – PCD, MEBA? ___________
If Yes, supply information covering ALL such employment
COMPANYSHIP RATING FROM TO
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
P. 2 of 4
DSA-02AAM 4-03
List all Employment in the last three (3) years not listed above (use separate sheet if necessary)
COMPANY CITY/STATE POSITION FROM TO
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
__________________ _______________ ______________ _______ ________
III. EDUCATION
Are you a graduate of a Maritime Academy? ________________
(Yes or No)
Name ___________________________________ Graduation Date ________________
What is the Highest Level of Education for which you have received a diploma?
__________________________________________ |
________________________ |
(Elementary, High School, Undergraduate School, Graduate School) |
(Total Years) |
__________________________________________ |
________________________ |
(Name of School) |
(City, State) |
What degrees do you have (if any)? __________________________________________
________________________________________________________________________
What USCG or MSC approved courses have you completed in the last 5 years:
NAME OF COURSE |
NAME OFSCHOOL |
COMPLETION DATE |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
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P. 3 of 4 |
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DSA-02AAM 4-03 |
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NAME OF COURSE |
NAME OF SCHOOL |
COMPLETION DATE |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
______________________ |
____________________________ |
__________________ |
IV. UNION AFFILIATIONS
Present Union Affiliations (Refer to Obligation for other licensed marine officers’ organizations):
Name _________________________________ Status ___________________________
(Present Union and Local)(Member, Applicant, Journeyman, Apprentice)
Former Union Affiliations Other Than District No. 1 – PCD, MEBA:
Name ________________________________ Status ____________________________
(Former Union and Local) |
(Suspended, dropped, expelled, withdrew) |
V. OATH
I swear or affirm that I do not believe in, nor am I a member of, nor do I support any organization that believes in or teaches or advocates the overthrow of the United States Government by force or by illegal or unconstitutional methods. I swear or affirm that I am not at present, nor have I ever been a member of the Communist Party. I swear or affirm that all the statements and information on this application are true.
Signature of Applicant _________________________________
Signature of Witness ______________________________ Date ___________________
P. 4 of 4
DSA-02AAM 4-03
MEBA MEMBER & APPLICANT DATA SHEET
Name: _______________________________________ Nickname: _____________
(Last) (First) (M.I)
___________________________ |
_____________________ |
__________________ |
(Social Security Number) |
(Home Phone Number) |
(Cell Phone Number) |
Address of Record: |
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_______________________________ ____________________________ _________
(Street Address)(City, State)(Zip)
Mailing Address:
_______________________________ ____________________________ _________
(Street Address)(City, State)(Zip)
___________________________________ _______________ ____________________
(E-mail address)(MEBA Book Number) (Book Issued: Mo/Day/Yr
_______________________ |
____________________________ |
__________________ |
(Birth Date) |
(Birthplace: City/State/Country) |
(Date Naturalized, City) |
__________________________________ _____________ _________ ____________
(Current License)(License Number) (Issue Number) (Expiration Date)
_______________________________________________ |
_____________________ |
(MMD Endorsements) |
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(MMD Expiration) |
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_______________________________________________ |
_____________________ |
(STCW Endorsements) |
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(STCW Expiration) |
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_______________________ _____________________ |
______________________ |
(Passport Number) |
(Passport Expiration) |
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(Original License Training Obtained) |
Next of Kin: |
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____________________________________ |
_____________________________ |
(Name: Last, First) |
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(Relationship) |
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_______________________________________________ |
________________________ |
(Contact Address) |
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(Phone Number) |
Personal Information: |
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_____________________ |
____________________________ __________________ |
(Status: Single, Married, Divorced) |
(Name of Spouse) |
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(Number of Dependents) |
___________________ |
________________ |
________________ |
____________ |
(Height) |
(Weight) |
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(Eye Color) |
(Hair Color) |
Signature: _____________________________________ Date: ___________________
DISTRICT NO. 1-PCD, M.E.B.A. (AFL-CIO)
INITIATION FEE AGREEMENT
I understand and agree that as an Applicant for Membership in District No. l – PCD, M.E.B.A., I will pay the membership Initiation Fee of $4,000.00 in accordance with the terms and conditions set forth below:
1.I hereby agree that upon accepting employment through the offices of District No. l – PCD, M.E.B.A., I will pay the sum of $160.00 per month, each month, until the total sum of $4,000.00 is paid.
2.The first payment shall be due and owing thirty (30) days after I first accept employment through the offices of District No. l – PCD, M.E.B.A.
3.I understand that payments toward my Initiation Fee that become due and owing will be deducted from the proceeds of my vacation benefits, in accordance with the policy and procedures set up by the District.
4.Authorization for these deductions has been given by me on appropriate forms that were provided with my Application for Membership.
5.I understand that if my Initiation Fee is not paid in full within a 25-month
Period commencing when I first accept employment through the office of District No. 1-PCD, M.E.B.A., I will be obligated to complete payment of the outstanding balance of my membership Initiation Fee within thirty (30) days.
I further understand I will forfeit any monies paid toward my membership Initiation Fee if I do not comply with all the provisions of this Agreement.
_________________________________
Signature of Applicant
WITNESS:
_____________________________ _________________________________
Date
DSA-03IFA 4-03
(Affix Notary Public – Seal)
LIMITED POWER OF ATTORNEY
BY THIS DOCUMENT, KNOW THAT
I, _________________________________ Social Security No. _________________________ do hereby
nominate, constitute and appoint Secretary-Treasurer Bill Van Loo, or his successor at District No. 1- PCD, Marine Engineers’ Beneficial Association (AFL-CIO), 444 North Capitol Street, NW, Suite 800, Washington, DC 20001, my lawful attorney to act for me and in my place for the period of five (5) years from the date below, for the following specific purposes:
1.To open any envelope addressed to me care of District No. 1-PCD, M.E.B.A., 444 North Capitol Street, NW, Suite 800, Washington, DC 20001 whether delivered by hand or through the United States Mail or other commercial delivery service from the M.E.B.A. Vacation Plan and to take any check or checks made to my order by the M.E.B.A. Vacation Plan as payment of vacation benefits.
2.To endorse my name on such checks or checks for me and in my name from the M.E.B.A. Vacation Plan and to deposit such check in any bank account of District No. 1-PCD, M.E.B.A., for the credit of District No. 1-PCD, M.E.B.A.;
3.To deduct from the proceeds of such check or checks received from the M.E.B.A. Vacation Plan a sum equal in amount to the amount of initiation fee and/or vacation dues or service charge then due and owing from me to District No. 1-PCD, M.E.B.A. in accordance with the By-Laws of District No. 1-PCD, M.E.B.A. and its applicable rules and regulations;
4.To mail to me at the address specified on the M.E.B.A. Vacation Plan Authorization form a check from District No. 1 - PCD, M.E.B.A. in a sum equal to the balance remaining from the amount of the M.E.B.A. Vacation Plan check after making the appropriate deductions together with a written statement of account setting forth the amount of the M.E.B.A. Vacation Plan check, the amount deducted for dues or service charge and the balance remaining from the check and to mail to me a written statement of account, and the amount, if any, of dues or service charge still due and owing by me to District No. 1- PCD, M.E.B.A.
I hereby give and grant power of attorney to do and perform every act necessary to complete the acts referenced above as fully as I might or could do were I personally present, with full power of substitution, hereby ratifying and confirming all that my said attorney in fact shall lawfully do or cause to be done by virtue hereof.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this _____ day of ___________ 20____.
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_________________________________________ |
In presence of: |
(Full Signature of Applicant) |
FOR THE STATE OF: |
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COUNTY/PARISH/BOROUGH OF: |
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On this _____ day of ___________, 20_____ before me personally appeared_______________________,
to me personally known and known to me to be a person who executed the foregoing power of attorney and duly acknowledged that he/she executed the same.
________________________________________
(Signature of Notary)
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
VOLUNTARY RELINQUISHMENT OF JOB
I, _________________________________, understand, as an applicant for
membership in the District No. 1- PCD, MEBA, will, since I am shipping on their contracted vessel, voluntarily relinquish any job received through this organization, if I fail to become an elected member of this organization within the required time.
SIGNED_________________________ DATE________________
PRINT NAME___________________________________
WITNESS________________________________________
DISTRICT NO. 1-PCD, M.E.B.A. (AFL-CIO)
M.E.B.A. Vacation Plan Authorization
To: M.E.B.A. Vacation Plan
1007 Eastern Ave.
Baltimore, MD 21202
Attn: M.E.B.A. Vacation Plan Administrator:
For the period of five (5) years from the date below, please send to me any checks for vacation due me under the M.E.B.A. Vacation Plan for which I may from time-to-time file the appropriate vacation claim care of District No. 1 – PCD, M.E.B.A. (AFL-CIO), Suite 800, 444 N. Capitol Street, N.W., Washington, D.C., 2001,
Very Truly Yours,
______________________________ |
________________ |
(Signature) |
(Date) |
___________________________ |
_____________________________ |
(Print Name) |
(Social Security Number) |
___________________________________
(Address of Record)
___________________________________
(City, State, Zip)
WITNESS________________________________________
DSA-06VPA 4/03
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
OBLIGATION
I, of my own free will and accord, do hereby solemnly and sincerely promise, swear and affirm that I will never reveal any of the signs, grips or passwords, nor impart any of the business or proceedings of any meeting of the District No. l – PCD, MEBA (AFL-CIO) to any person not duly and justly qualified to receive same. I also bind myself not to join or belong to any other organization of licensed marine officers while I am a member or an applicant of this Organization. I will faithfully obey and use my earnest endeavors to carry out the provisions of the Constitution, By-Laws, Rules and Regulations of the National Marine Engineers’ Beneficial Association (AFL-CIO) and of this Organization and its Affiliates.
I have carefully read and signed the Obligation of my own free will and accord. It being understood that it in no way will interfere with my Social, Political or Religious rights.
___________________________________________________ __________________
(Signature of Applicant)(Date)
______________________________________ |
_______________________________ |
(Print Name of Applicant) |
(Social Security Number) |
Witness: _____________________________________________________________
DSA-07Obl: 4-03
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
ACKNOWLEDGEMENT OF DUTIES
1.Whereas the undersigned has made application for membership in District No. 1 – MEBA for the purpose of sailing as a licensed marine officer aboard merchant vessels; and
2.Whereas in addition to being an integral part of commerce and trade, the United States Merchant Marine plays an important part in carrying out the foreign policy of the United States Government; and
3.Whereas the Merchant Marine’s role in carrying out foreign policy includes the transport of troops, munitions and other supplies for military forces of the United States and her allies to various parts of the world as required by the foreign policy:
LET IT BE KNOWN that the undersigned hereby acknowledges the above and further states that he will not refuse employment on a vessel, secured through the hiring hall of District No. 1 – PCD, MEBA carrying cargoes implementing American foreign policy as described in No. 3 above and will serve aboard vessels having such cargoes.
____________________________________ |
________________________________ |
(Print Name of Applicant) |
(Signature of Applicant) |
_____________________________________ |
________________ |
(Witness) |
(Date) |
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____________________________________ |
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(Signature of Parent or Legal Guardian) |
____________________________________ |
______________ |
(Print Name of Parent or Legal Guardian) |
(Relationship) |
(In the event the Applicant is under the age of 21 years, this Agreement must be signed by one of the Parents of the Applicant or his Legal Guardian.)
DSA-08AOD 4-03
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
Effective Date of Application
To: DIC
D1-PCD, MEBA (AFL-CIO)
444 N. Capitol Street, NW
Suite 800
Washington, DC 20001
Dear Sirs:
I was an individual who through an immediate need of the Union was unable to complete the application before joining the MEBA contracted vessel,
________________________ on ____________ as ___________________.
(Name of Vessel) |
(Mo/Day/Yr) |
(Position) |
Attached find a copy of the dispatch for the vessel, a copy of the receipt for payment of the service fee from that quarter and a copy of the certificate of discharge for the vessel also showing completion of assignment. I request to have my Date of Application backdated to reflect the date of dispatch. I understand this is only effective for any assignments made after January 1, 2003.
Very Truly Yours, |
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______________________________ |
________________ |
(Signature) |
(Date) |
___________________________ |
_____________________________ |
(Print Name) |
(Social Security Number) |
Union Official’s Signature__________________________________ SEAL
(Verifying documents and Immediate Need)
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
APPLICANT IDENTIFICATION FORM
The following information is requested with your Authorization and Application for Membership in order for District No. 1-PCD, MEBA (AFL-CIO) to be in compliance with the regulations issued by the Equal Employment Opportunity Commission under Title VII of the Civil Rights Act of 1964.
Please check the applicable boxes:
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Male |
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Female |
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White |
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Black |
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Hispanic |
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Asian or Pacific Islander |
American Indian or Alaskan Native
None of the above
I understand that this form is for self-identification and will not be used for any other purpose than the filing of the required reports to the Equal Employment Opportunity Commission.
__________________________________________
(Signature of Applicant)
__________________________________________
(Witness)
_____________________
(Date)
District No. 1-PCD, MEBA (AFL-CIO)
Deep-Sea Applicant Information Fact Sheet
(Attachment for Application for Membership under the March 2003 provisions, for the Deep-Sea Bargaining Unit)
Your Application is subject to the following terms and conditions:
1.Governing Rules and Regulations
Unless otherwise specifically modified by this attachment to your application for membership, your application for membership is subject to all the rules, regulations, terms and conditions contained in the National MEBA Constitution, the Constitution of District No. 1-PCD, MEBA, the By-Laws of District No. 1-PCD, MEBA, the Shipping Rules, and the Rules and Regulations promulgated by the National Executive Committee and/or the District Executive Committee (DEC) currently in effect or as may be amended in the future. The applicants attention is directed to rules and regulations, number 3, regarding applications for membership in the National MEBA and a duly affiliated District thereof.
2.Licensing Requirement
a.Possession one of the following licenses:
i.Current and Valid Third Assistant Engineer, Steam or Motor or Gas Turbine of Any Horsepower Upon Oceans.
ii.Current and Valid Third Mate Steam or Motor Vessels of Any Gross Registered Tons Upon Oceans.
3.Sailing Time
a.Restrictions
i.Only licensed officer time on MEBA deep-sea contracted vessels, completed per the Union dispatch slip, shall qualify. Copies of the dispatch slip and also certificate of discharge or certificate of employment (for ROS) must be provided. Early termination of an assignment due to any of the following shall disqualify such time for this Application:
1.Discharge/Firing
2.Termination under any probation clause
3.Quitting under mutual consent before completion of assignment
DSA-12IFS 4/03; P.1 of 5
ii.For ROS vessels, sailing time shall accrue at the rate of five (5) days for every seven (7) days aboard the vessel. Total ROS time may not exceed one hundred and twenty (120) days credit toward completion of this Application in Section 9.
iii.A combined total of thirty (30) days sailing time may be used towards the sailing time requirements for successfully completed assignments under the Washington State Ferry contracts or any other non-deep-sea unit that participates in the MEBA Pension Plan.
iv.Vacation time will not count as sailing time.
v.Submission to the Union, within twelve (12) months of the date of the Application, proof of successful completion of sixty (60) days of licensed sailing time on MEBA deep-sea contracted vessels subject to the same requirements and limitations above. Failure to complete this provision shall render this application null and void.
vi.The Applicant must also submit within twelve (12) months of the date of Application, two (2) letters of recommendation from a Chief or 1st Assistant Engineers for engineering applicants or from a Master or Chief Mate for deck applicants with whom they have sailed for at least thirty (30) days as a licensed officer under a MEBA contract after the effective Date of Application. Failure to complete this provision shall render this application null and void.
b.Other Time
Except as provided in Section 3 (a) (iii) above, time in any other non-deep-sea bargaining units, port relief time, vacation time, port engineer time, time with federal government fleets (Navy, MSC, ACOE, NOAA), state government fleets and local government fleets shall not count.
4.Initiation Fee Agreement and Application Forms
You must sign an initiation fee agreement, complete the proper authorization and application for membership forms with all attached papers thereto. The application must be reviewed and witnessed by a Union Official of the District and filed with the District Headquarters for a District Investigating Committee (DIC) review.
5.Service Charges
You agree to pay the regular service charge quarterly and in advance during the period of your applicant status and thereafter if elected into membership. The current quarterly service charge is $100 dollars per calendar quarter and is subject to change. The current initiation fee is $4,000 and its payment, etc., is covered in the initiation fee agreement.
6.Initial Payment of Service Charge
At the time you apply for membership, you must submit payment of one-quarter’s service charge. The District in its discretion may reject your application making it null and void and without recourse. Your application for membership will then be null and void and notification will be mailed to you at your address of record. Service charge payments are not refundable.
7.Initial Status of Applicant
Upon acceptance of your authorization and application for membership, you will be classified as an applicant for membership under the District’s deep-sea applicant for membership program.
8.Application for Group Card
In accordance with DEC policies and the shipping rules, your initial group shipping status will be Group III. A group shipping card will be issued to you at the time your applicant book is issued. An application for your applicant book and group shipping card may be made at any MEBA Branch office.
The openings in Group II are filled by oldest date of application. To be admitted into Group II when there are openings, you must have on file with MEBA Headquarters 150 days of sailing time (as defined in the shipping rules) from the date of this application. Group II to Group I is generally by total sailing time when there are openings as determined by the District and without regard to date of application.
Any changes (including Group III to Group II and Group II to Group I) are governed by the shipping rules, which may be amended from time to time. All renewals of or changes in group shipping status will be in accordance with the shipping rules and DEC policy in effect at the time of renewal or change.
Any application being denied and deemed null and void by the District shall also immediately result in the revocation of all group shipping privileges.
9.Consideration for Membership
You must complete 200 days of sailing time after the date of application, not including vacation time. Only days completed per Section 3 shall qualify.
Initiation fees must be paid in full. Regular service charges to the District must be paid for a minimum of two (2) years (eight quarters). Any other requirements must be completed. You must verify this information and submit same to the DIC at MEBA Headquarters. The local branch can assist you.
This will act as your request for a review of your application for membership. The DIC meets from time to time and your application for membership will be reviewed in turn and in accordance with the requirements contained in this fact sheet and further subject to all the requirements of all deep-sea applications for membership, unless modified herein. Any negative letters, letters not to recommend or facts contained in the file will be investigated and may delay the membership process or may result in your application being denied and being declared null and void.
The DIC will then issue a report with its recommendations to the membership to vote on at the regular monthly membership meeting. If you are accepted by the membership as a member, you will then be advised of your acceptance and you may apply for your membership book.
10.Failure to Complete Application Requirements
The stated purpose of this program is to obtain new members for the deep-sea bargaining unit. The Union therefore expects the applicant will complete all the requirements set forth in this program within five (5) years from the date of application and any failure to complete all the requirements will forfeit and void the authorization and application which was made by you for membership.
11.Effective Date of Application
The Date of Application shall be the date upon which the completed application is submitted to a Union Official to be reviewed and witnessed and filed with the District Headquarters for a District Investigating Committee (DIC) review.
For those individuals who through an immediate need of the Union are unable to complete the application before joining the MEBA contracted vessel. They may with a copy of the dispatch for the vessel, receipt for payment of the service fee from that quarter, certificate of discharge for the vessel showing completion of assignment and a signature and seal of a Union Official who is familiar with the assignment, have their Date of Application backdated to reflect the date of dispatch. This is only effective for any assignments made after January 1, 2003.
12.Closing the Books
The Union at its sole discretion shall have the right to open or close the books to Applications when it so chooses by direction of the District Executive Committee.
I hereby certify that I have honestly and fully completed each and every part of my authorization
and application for membership and I have read, understood, and agreed to all of the above
provisions including the District’s discretion to reject my application making it null and void and
without recourse, as witnessed in my hand and seal this ___________ day of
______________________, ____________.
__________________________________(SEAL)
Signature of Applicant
_______________________________
Print Name of Applicant
I, _________________________________, a full-time Union Official of District No. 1-PCD,
MEBA, do hereby verify the above named Applicant in signing this deep-sea applicant information fact sheet; has read, understands and agrees to the terms and conditions provided by the information attached hereto as part of this application and all of its parts and do make my seal against the signature of the Applicant.
_______________________________ |
_______________________________ |
Union Official Signature |
Title |
Date: ___________________________ |
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(If not signed in front of a full-time Union Official of District No. 1 – PCD, MEBA then it must be notarized below and sealed upon the Applicants Signature)
_________________________________ |
_________________________ |
Notary’s Signature |
Notary’s Printed Name |
Being a Notary for __________________________ whose term expires _____________
Municipality and/or State |
Date |
DSA-12IFS 4/03; P.5 of 5
M.E.B.A. Political Action Fund
Marine Engineers’ Beneficial Association
444 North Capitol Street, N.W.
Suite 800
Washington D.C. 20001
Yes, I want to support the Political Action Fund (PAF) to promote the concerns of members through M.E.B.A.’s legislative and political activities.
□I hereby authorize and direct the M.E.B.A. Vacation Plan to deduct from my gross vacation earnings and remit to the M.E.B.A. PAF my voluntary contribution per month of:
□ $50 |
□ $75 |
□ $100 □ $250 □___% □___Other |
□Instead, enclosed please find my check made payable to the M.E.B.A. PAF for $___.
Name:__________________ Signature:____________________________
Mailing Address________________________________________________
Date:_____________ Social Security # (last 4 digits)___________________
Email Address:_______________________ Cell #_____________________
You are free to contribute more or less than the suggested amounts above. PAF contributions are voluntary and not a condition of membership in or employment through the M.E.B.A. You may refuse to contribute without reprisal. The M.E.B.A.’s PAF will use voluntary contributions for purposes including, but not limited to, making contributions to and expenditures for candidates for federal, state, and local offices. Contributions to the PAF are not deductible as charitable contributions for federal tax purposes. Federal law requires political committees to report to the Federal Election Commission each individual whose contributions aggregate in excess of $200 in a calendar year. This authorization shall remain in full force and effect until revoked in writing by me to the Administrator of the M.E.B.A. Vacation Plan.
Instructions for Completing Permanent Data Forms
You must complete a Permanent Data Form if you are a new Participant, if you are adding a Dependant, if your marital status changes, or if your dependant’s eligibility status changes.
The following documents must be included with your completed Permanent Data Form:
Married
•If you are married – a copy of your marriage certificate.
Children
•Biological children – a copy of each child’s birth certificate.
•Adopted children – a copy of each child’s adoption papers and birth certificate.
•Stepchildren – a copy of each child’s birth certificate, a copy of your most recent IRS tax filing, a copy of that part of your spouse’s divorce decree that assigns responsibility for the stepchild’s medical care.
•Grandchildren - a copy of each child’s birth certificate, proof of legal custody awarded by a court or state agency, a copy of your most recent IRS tax filing, (additional documentation may be required).
Dependant Parents
•Dependant Parents – a copy of your most recent IRS tax filing as proof that you claim your parent as a de- pendant on your tax return. You will be required to provide proof of support of your parent(s) annually.
Your parent(s) may be covered as a dependant only if:
(1)you do not have a spouse, you do not have natural or adopted children under the age of 26, and you do not have stepchildren under age 19 (or 23, if full-time students); and
(2)you contribute at least one-half of the support of the parent being claimed as a dependant, claim your parent as a dependant on your IRS tax return, and you submit a copy of your most recent IRS tax filing as proof of support.
Additional Requirements for Adult Children (over age 18)
Biological and Adopted Children Age 19 through 25
•Your biological and adopted adult children under the age of 26 may be covered as a dependant provided they are not eligible for other employment based coverage (other than parent’s coverage). Employment based coverage is coverage that an adult child is eligible for due to the employment of the child or the child’s spouse, regardless of whether the child enrolls in such coverage.
•You are required to verify the availability of employment based coverage for each biological and adopted adult child each year.
Stepchildren and Grandchildren
•Your stepchildren and grandchildren age 19 through age 22 may be covered as a dependant provided they are full-time students.
•Student status forms are available from the Plan Office or on the Plan website (www.mebaplans.org).
•You are required to verify full-time student status for each stepchild and/or grandchild each year.
Change in Marital Status
Marriage
•If you are single and become married, you must notify the Plan Office and submit a copy of your marriage certificate with your new Permanent Data Form to enroll your new spouse.
Divorce or legal separation
•If you are married and become divorced or legally separated, you must notify the Plan Office immediately and submit a copy of your divorce decree, legal separation agreement or your written agreement to live sep- arately within 30 days, along with your new Permanent Data Form.
•If you are divorced and are keeping your children as dependants in the Plan, you must provide additional information about other coverage the children may have, such as through your former spouse (or his or her new spouse, if remarried), so that the Plan can properly coordinate benefits. If included in your divorce de- cree, a copy of the portion that assigns responsibility for medical care may be needed to determine order of payment.
Address and Address Changes
•If you use a PO Box as either your permanent address or your mailing address, you must also provide a physical address.
•If you are advising the Plan of a change of address only and have no other changes to make you can com- plete a new Permanent Data Form or you can simply notify the Plan Office in writing of the address change. Include your name and social security number. The Participant must sign this notification in order to allow the Plan Office to change your address.
IMPORTANT - When Coverage Terminates
If you and/or your dependant no longer meet the eligibility requirements your coverage and/or your dependant’s coverage will end. You are required to notify the Plan Office in writing and within 30 days of events that impact your and/or your dependant’s eligibility under the Plan. Events that may lead to ineligibility and a loss of coverage under the Plan include, but are not limited to:
•Failure to report a divorce;
•Failure to report a legal separation;
•Failure to report a child’s eligibility for other coverage, including the availability of such coverage;
•For stepchildren and grandchildren, failure to report a change in student status, a change in resi- dency or a change in support;
•For stepchildren and grandchildren, failure to report a child’s marriage;
•For grandchildren, failure to meet the grandchild eligibility rules; and
•Failure to pay any required premiums (e.g., COBRA, pensioner contributions, Alternate Plan pre- miums) timely.
•For Pensioners, return to work under certain circumstances without the permission of the Trustees.
If you do not timely notify the Plan Office of an event that causes a change in your or your depen- dant’s eligibility under the Plan, you will be required to reimburse the Plan for benefits that were paid after your and/or your dependant’s coverage terminated.
In addition, your or your dependant’s coverage under the Plan may be terminated retroactively in the case of fraud or intentional misrepresentation.
MEBA Medical & Benefits Plan 1007 Eastern Avenue |
Baltimore, MD 21202-4345 |
410-547-9111 * 800-811-MEBA (6322) * 410-547-6665 |
(Fax) * www.mebaplans.org |
PERMANENT DATA FORM
COMPLETE BOTH PAGES OF THIS FORM , SIGN AND DATE WHERE INDICATED, AND RETURN TO THE PLAN OFFICE IN BALTIMORE
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Member Name |
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Last Name |
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First Name |
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Social Security Number |
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Date of Birth (mm/dd/yyyy) |
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Sex |
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○ Male |
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(Select one) |
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○ Female |
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Home Telephone Number |
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Cellular Phone Number |
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E-mail address (If applicable) |
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@ |
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Affiliation (Check One) |
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○ District No. 1-PCD, MEBA ○ Plan Employee ○ Union Employee ○ Other: |
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Active/Pensioner (Check One) |
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○ Active ○ Pensioner |
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If Actively Employed, Name of Present Employer: |
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Marital Status |
(Check One) |
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○ Single ○ Married ○ Widowed ○ Divorced |
○ Legally Separated |
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Date Married, Widowed, Divorced |
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○ Married ○ Widowed |
○ Divorced ○ Legally Separated |
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or Legally Separated (mm/dd/yyyy) |
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Permanent Address |
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Number & Street |
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(Home of Record): |
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City, State, Zip |
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Mailing Address |
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Number & Street |
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(if different than Permanent Address |
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above): |
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City, State, Zip |
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DEPENDANTS TO BE ADDED TO YOUR MEDICAL COVERAGE |
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(LIST FULL NAMES) |
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STEP/GRAND |
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DATE OF BIRTH |
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RELATIONSHIP |
CHILD |
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LAST NAME |
FIRST NAME |
INITIAL |
(MM/DD/YYYY) |
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DEPENDANT SSN |
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TO MEMBER |
CHECK IF |
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CHECK ONE |
FT STUDENT |
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○ Spouse |
○ Yes |
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○ Child |
○ Adopted Child |
○ No |
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○ Stepchild ○ Grandchild |
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If dependant is an adult child/adopted child, is he or she eligible for Employment Based Coverage? (check one)
If eligible for Employment Based Coverage, complete the following sections
Child’s Spouse’s Employer Name
Child’s Spouse’s Employer Address
Child’s Spouse’s Employer Phone
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STEP/GRAND |
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DATE OF BIRTH |
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RELATIONSHIP |
CHILD |
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LAST NAME |
FIRST NAME INITIAL |
(MM/DD/YYYY) |
DEPENDANT SSN |
TO MEMBER |
CHECK IF |
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CHECK ONE |
FT STUDENT |
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○ Child |
○ Adopted Child |
○ Yes |
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○ Stepchild ○ Grandchild |
○ No |
If dependant is an adult child/adopted child, is he or she eligible for Employment Based Coverage? (check one) ○Yes ○ No If eligible for Employment Based Coverage, complete the following sections
Child’s Spouse’s Employer Name
Child’s Spouse’s Employer Address
Child’s Spouse’s Employer Phone
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STEP/GRAND |
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DATE OF BIRTH |
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RELATIONSHIP |
CHILD |
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LAST NAME |
FIRST NAME INITIAL |
(MM/DD/YYYY) |
DEPENDANT SSN |
TO MEMBER |
CHECK IF |
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CHECK ONE |
FT STUDENT |
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○ Child |
○ Adopted Child |
○ Yes |
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○ Stepchild ○ Grandchild |
○ No |
If dependant is an adult child/adopted child, is he or she eligible for Employment Based Coverage? (check one) ○ Yes ○ No If eligible for Employment Based Coverage, complete the following sections
Child’s Spouse’s Employer Name
Child’s Spouse’s Employer Address
Child’s Spouse’s Employer Phone
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STEP/GRAND |
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DATE OF BIRTH |
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RELATIONSHIP |
CHILD |
LAST NAME |
FIRST NAME |
INITIAL |
(MM/DD/YYYY) |
DEPENDANT SSN |
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TO MEMBER |
CHECK IF |
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CHECK ONE |
FT STUDENT |
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○ Child |
○ Adopted Child |
○ Yes |
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○ Stepchild ○ Grandchild |
○ No |
If dependant is an adult child/adopted child, is he or she |
eligible for Employment Based Coverage? (check one) ○ Yes ○ No |
If eligible for Employment Based Coverage, complete the following sections |
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Child’s Employer Name |
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Child’s Employer Address |
Child’s Employer Phone |
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Child’s Spouse’s Employer Name |
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Child’s Spouse’s Employer Address |
Child’s Spouse’s Employer Phone |
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(Attach a separate sheet to your Permanent Data Form if you have more than four Dependants)
FORM IS NOT VALID IF NOT SIGNED AND DATED BY PARTICIPANT
FORM WILL BE RETURNED IF NOT SIGNED AND DATED.
PAGE 2 OF 2
DISTRICT NO. 1-PCD, MEBA (AFL-CIO)
DEEP SEA FOLLOW-UP VERIFICATION FORM
For all individuals who applied under the 2003 provisions
TO: District Investigating Committee (DIC)
444 N. Capitol St, NW Suite 800,
Washington, DC 20001
______________________
(Today’s date)
_______________________________________ |
_____________________________ |
(Applicants Name: Please Print) |
(Date of Application) |
SSN: ___________________________ |
Port: ________________________ |
In accordance with provisions of the Deep-Sea Applicants Information Fact Sheet, attached hereto are proof of successful completion of sixty (60) days of licensed sailing time on MEBA deep-sea contracted vessels within twelve (12) months of the date of application and a list with verifications of required sailing time.
Also in accordance with the Deep-Sea Applicants Information Fact Sheet,
attached hereto is two letters of recommendation or the indication that one or both letters of recommendation have been forwarded to Headquarters directly
List sailing time in chronological order starting with the most recent time first and attach copies of discharges or letters of employment and also union dispatch slips. Sailing time must be under a District No. 1-PCD, MEBA (AFL-CIO) deep-sea contracted vessel. ROS time will only count five (5) for seven (7) days. Sailing time on Washington State Ferries or other non deep-sea unit that participates in the Pension Plan for completed assignments will count for up to thirty (30) days combined total. Time in other bargaining units, including federal, state and local government fleets, does not count. Vacation time, Port Relief or CMES time does not count.
NOTE: The sailing time and letter of recommendation requirements must be completed within one year from the date of application. If you are working as a licensed officer under a District No. 1-PCD, MEBA Deep-sea contract when the one-year expires, the time will automatically be extended to the completion of your assignment plus reasonable and necessary processing time.
Continued next page
DSA-15FVF 4/03
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DATES |
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VESSEL |
FROM |
TO |
DAYS______ |
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Total Days: ____________________
I hereby certify that the above time was after my date of application and was for completed assignments.
Attached find ____________ letters of recommendation. _____________ letters of
(0,1, or 2) |
(0, 1, or 2) |
recommendation have already been submitted to Headquarters. |
________________ |
__________________________________ |
Date |
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Applicant’s Signature |
SPACE BELOW FOR UNION USE ONLY
I hereby certify that I have verified the above submitted sailing time is for completed assignments. I have attached the two required letters of recommendation or if one or both letters are not attached, I have verified that the missing letter(s) have been received by Headquarters.
Port of: _____________________________________ |
Date: _________________ |
Verified by: __________________________________ |
______________________ |
(Signature of Union Official) |
(Title of Union Official) |
NOTE: Although Dispatcher or other Office staff can assist with the verification process, the verification must be reviewed and signed by a full-time union official.
DSA-15FVF 4/03
District No.1-PCD, MEBA
(AFL-CIO)
MEMORANDUM
To: |
All MEBA Member Chief Engineers, Masters, |
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First Assistant Engineers and Chief Mates |
From: |
District Investigating Committee (DIC) |
Date: |
April 2003 |
Subject: |
New Applicants |
New Applicants to the Union must submit within twelve (12) months of their date of Application, two (2) letters of recommendation from a Chief or 1st Assistant Engineers for engineering applicants or from a Master or Chief Mate for deck applicants with whom they have sailed for at least thirty (30) days as a licensed officer under a MEBA contract after their effective Date of Application. The MEBA’s goal is to seek evaluations of new applicants to determine if they have the potential to be good Union members and good licensed officers. If you feel the individual applicant has the potential to be a good Union member and a good licensed officer, please give them your recommendation.
The District Investigating Committee is very concerned and needs to know if this Applicant does not meet the criteria of having the potential to be a good Union member and also a good licensed officer. If this is the case, please complete a letter to not recommend the applicant for membership. During any time in the application process that is at least 25 months from the Date of Application, any negative letters, letters not to recommend or facts contained in the file of the Applicant will be investigated and may delay the membership process or may result in their application being denied and being declared null and void.
The letter can be on ship’s letterhead or the Union’s standard recommend/not recommend form and given to the individual or sent to Headquarters. The Headquarters address is:
D1 – PCD, MEBA
Attention: DIC
444 North Capitol St, NW
Suite 800
Washington, DC 20001
Thank you for your time and attention in participating in this important process. You are an important part of the MEBA’s process that determines if our applicants are suitable to gain the privilege of membership. We appreciate your help.
TO: District Investigating Committee (DIC), District No. 1-PCD, MEBA (AFL-CIO)
FROM: ____________________________________ ____________________________
(Print Name)(Title – C/E, Master, 1/E or C/M)
SUBJECT: Letter to Recommend/ Not Recommend Applicant for Membership
(Circle One)
FOR: ________________________________SSN of Applicant: ___________________
(Please Print Applicant’s Name)(If known)
I am the _____________________ of the __________________________________ and a
(Title – C/E, Master, 1/E or C/M)(Name of Ship)
member of District No. 1-PCD, MEBA (AFL-CIO) (D1-MEBA) _________________.
(Book Number)
The above named individual has sailed under the authority of their license as a
____________________________ for approximately _________________________ days.
(Title/Position)(30 days minimum required)
His/her assignment started on ________________ and ended on ____________________.
(Date)(Date)
When I left the _____________________________ on _________________ the individual
(Name of Ship)(Date)
completed the assignment/ did not complete the assignment/ was still onboard.
(Circle One)
I have observed this applicant’s job performance and union attitudes and
recommend/ do not recommend him/her for membership in our Union, D1-MEBA.
(Circle One)
Comments: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Use Separate Page or Back for Additional Comments and indicate below)
Fraternally Submitted, |
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_________________ |
_________________________________ |
___________________ |
(Date) |
(Signature of Member) |
(Title – C/E, Master, 1/E or C/M) |
Additional Comments: |
Enclosed/ Over/ None |
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(Circle One) |
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NOTE: This letter can be given to the engineer/mate to forward to Headquarters or it can be forwarded
directly to Headquarters: Attention: DIC, District No. 1-PCD, MEBA (AFL-CIO), Suite 800, 444 North
Capitol St, NW, Washington, DC 20001
TO: District Investigating Committee (DIC), District No. 1-PCD, MEBA (AFL-CIO)
FROM: ____________________________________ ____________________________
(Print Name)(Title – C/E, Master, 1/E or C/M)
SUBJECT: Letter to Recommend/ Not Recommend Applicant for Membership
(Circle One)
FOR: ________________________________SSN of Applicant: ___________________
(Please Print Applicant’s Name)(If known)
I am the _____________________ of the __________________________________ and a
(Title – C/E, Master, 1/E or C/M)(Name of Ship)
member of District No. 1-PCD, MEBA (AFL-CIO) (D1-MEBA) _________________.
(Book Number)
The above named individual has sailed under the authority of their license as a
____________________________ for approximately _________________________ days.
(Title/Position)(30 days minimum required)
His/her assignment started on ________________ and ended on ____________________.
(Date)(Date)
When I left the _____________________________ on _________________ the individual
(Name of Ship)(Date)
completed the assignment/ did not complete the assignment/ was still onboard.
(Circle One)
I have observed this applicant’s job performance and union attitudes and
recommend/ do not recommend him/her for membership in our Union, D1-MEBA.
(Circle One)
Comments: ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Use Separate Page or Back for Additional Comments and indicate below)
Fraternally Submitted, |
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_________________ |
_________________________________ |
___________________ |
(Date) |
(Signature of Member) |
(Title – C/E, Master, 1/E or C/M) |
Additional Comments: |
Enclosed/ Over/ None |
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(Circle One) |
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NOTE: This letter can be given to the engineer/mate to forward to Headquarters or it can be forwarded
directly to Headquarters: Attention: DIC, District No. 1-PCD, MEBA (AFL-CIO), Suite 800, 444 North
Capitol St, NW, Washington, DC 20001
Non-Discrimination Notice
The Marine Engineers’ Beneficial Association (M.E.B.A.) does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, applying for membership in M.E.B.A., membership in M.E.B.A., hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, and clients.
M.E.B.A. is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against discrimination in membership, employment, recruitment, advertisements for employment, compensation, termination, upgrading, promotions, and other conditions of employment against any employee or job applicant on the bases of race, color, gender, national origin, age, religion, creed, disability, veteran's status, sexual orientation, gender identity or gender expression.
