Associate Member Checkoff Authorization Form

Member Information

Your First Name

Your Last Name

Date of Birth

Social Security Number

(This information is required in order to sign you up as a UMWA Member, it will not be shared with any entity outside of the union.)

Your Phone Number

Your Email

Your Mailing Address

Your Mailing City

Your Mailing State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Your Mailing Zip Code

Bank Account Information

I, the undersigned, do hereby voluntarily authorize the United Mine Workers of America every month to debit my account for monies due to the United Mine Workers of America by me in the amount of $5 per month for Associate membership dues. This assignment, authorization, and directive shall be in full force and effect until I authorize the termination of said deductions. I agree and direct that this assignment, authorization, and direction shall be automatically renewed annually unless written notice is given by me no more than twenty (20) days or not less than ten (10) days prior to the renewal date.

Bank Name

Account Type

CheckingSavings

Name on Account

Routing Number

Account Number

Address on Account

City

State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Your Signature

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