UNITED FEDERATION OF SPECIAL POLICE
AND SECURITY OFFICERS, INC.
Date: __________________
To(Security Employer): _____________________________________
You are authorized and directed to deduct from my wages or salary, as required by the United Federation of Security Officers, Inc., my membership dues and to remit same to the United Federation of Security Officers, Inc. This authorization is a voluntary act on my part and shall be irrevocable for a period of one year or until the termination of the collective bargaining agreement, whichever is sooner, and shall, however, renew itself from year to year unless the undersigned gives written notice to the United Federation of Security Officers, Inc.
Signature: _________________________________________________
Print the following information:
Name: ______________________________ Employee Nbr:__________
Address: _________________________________________ Apt:_____
____________________________________________________________
City: __________________________ State:____ Zip:____________
Social Security Number: ____________________________________
Date of Birth: ________________ Date of Hire: ______________
Job Title/Position ______________________ Full/Part-Time ___
Home Telephone Number: (____)_______________________________
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