UNITED FEDERATION OF SPECIAL POLICE AND SECURITY OFFICERS,INC

AUTHORIZATION FOR REPRESENTATION

I, the undersigned, designate United Federation of Special Police and Security Officers, Inc.,an employee organization, as my sole and exclusive representative for the purpose of negotiating collectively with my employer on my behalf on all matters pertaining to my wages and/or salary, hours, terms and conditions of employment.

NAME (please print)_________________________________________DATE:_____________________

ADDRESS_______________________________________________APT #_______________________

CITY________________________________________STATE__________ZIP_____________________

EMPLOYED BY_________________________________WORK SITE:__________________________

JOB TITLE____________________________HOME PHONE NBR__(_______)___________________

BIRTH DATE___________________________ SOCIAL SEC NBR:____________________________

EMPLOYEE SIGNATURE____________________________________