Checkoff Authorization Form

    Member Information

    Check One

    (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.)

    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.

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