Electronic Checkoff Form

Electronic Authorization Form

Member Information

Please select:
—Please choose an option—I am a coal minerI am a non-coal workerI am a construction worker

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

Your Employer

Date of Hire

I, the undersigned, do hereby voluntarily authorize and request the above-named company, or its successor, on each pay day hereafter to deduct from my wages (or earnings) all the amounts of money due to the United Mine Workers of America as membership dues (including initiation fees and assessments) or the equivalent thereof, and to promptly transmit and deliver the same to its duly authorized representative. This assignment. authorization and directive shall be irrevocable for the period of one (1) year. or until the termination of said agreement, whichever occurs sooner; and I agree and direct that this assignment, authorization and direction shall be automatically renewed and shall be irrevocable for successive periods of one (1) year each or for the period of each succeeding agreement whichever shall be shorter. unless written notice is given by me to both the company and the Union by registered mail not more than twenty (20) days or not less than ten (10) days prior to the expiration of each period of one (l) year, or of each agreement. whichever occurs sooner. By my signature, I hereby authorize the United Mine Workers of America to act as my representative in all matters concerning wages. hours. and other terms and conditions of employment.

Your Signature

Today's Date