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UNITED FEDERATION OF SPECIAL POLICE

AND SECURITY OFFICERS, INC.

 
540 North State Road
 
Briarcliff Manor, New York 10510
 
PAYROLL DEDUCTION AUTHORIZATION

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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