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Voluntary Authorization for Payroll Deduction

For Transport Workers Union of American, LOCAL 320, AFL-CIO


I hereby authorize the Company to deduct every payroll period from my earnings sum, as the company, in a manner to be determined, is advised from time to time by the Secretary Treasurer of the Transport Workers Union of America, Local 320, to be due the Union under the terms of the Union Constitution and Bylaws, and to remit the amount to the Secretary Treasurer, such sum to be full payment of membership dues per payroll period or as fees equal to the sum required by a Union Member. This authorization and assignment shall be irrevocable for a period of one year from the date of execution or until the termination of the current agreement between the Company and said Union, whichever occurs sooner. The Authorization shall be automatically renewed and shall be irrevocable for successive periods of one year each, or for the period of each succeeding applicable collective bargaining agreement, whichever shall be shorter, unless revoked by me in writing during the period of ten days immediately preceding the termination date of each period of one year of each applicable collective bargaining agreement, whichever period shall be shorter.

First Member Name

First Name*

Last Name*

Phone*
First Member Date of Birth*
First Member Information

Employer

Employee Number

Date of Hire
First Member Signature*
Second Member Name

First Name*

Last Name*
Second Member Date of Birth*
Second Member Information

Employer

Employee Number

Date of Hire
Third Member Name

First Name*

Last Name*
Third Member Date of Birth*
Third Member Information

Employer

Employee Number

Date of Hire
Fourth Member Name

First Name*

Last Name*
Fourth Member Date of Birth*
Fourth Member Information

Employer

Employee Number

Date of Hire
Fifth Member Name

First Name*

Last Name*
Fifth Member Date of Birth*
Fifth Member Information

Employer

Employee Number

Date of Hire
Sixth Member Name

First Name*

Last Name*
Sixth Member Date of Birth*
Sixth Member Information

Employer

Employee Number

Date of Hire
Seventh Member Name

First Name*

Last Name*
Seventh Member Date of Birth*
Seventh Member Information

Employer

Employee Number

Date of Hire
Eighth Member Name

First Name*

Last Name*
Eighth Member Date of Birth*
Eighth Member Information

Employer

Employee Number

Date of Hire
Ninth Member Name

First Name*

Last Name*
Ninth Member Date of Birth*
Ninth Member Information

Employer

Employee Number

Date of Hire
Tenth Member Name

First Name*

Last Name*
Tenth Member Date of Birth*
Tenth Member Information

Employer

Employee Number

Date of Hire
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information and updates by e-mail, phone, or text. Please use PERSONAL email address only.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Employer

Employee Number

Date of Hire
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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