Public Employees Checkoff Authorization Form

Public Employees Checkoff Authorization Form

Member Information

Please select if you are a State or Public or County Employee!
—Please choose an option—State EmployeePublic EmployeeCounty Employee

Select one that applies
—Please choose an option—I am a new member of the UMWAI am transferring Local Unions

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

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 authorized by the UMWA International Executive Board, consistent with Article 13 of the International UMWA Constitution, for membership dues (including initiation fees and assessments). 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. 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.

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

Today's Date