TWU COPE
Automatic Deduction Form for: Air Transport Division
(print page and fill out by hand)
TRANSPORT WORKERS UNION OF AMERICA
AIR TRANSPORT DIVISION
1700 Broadway, 2nd Fl., New York, NY 10019
AUTHORIZATION, ASSIGNMENT, AND DIRECTION FOR DEDUCTION
FROM PAYROLL FOR TWU POLITICAL CONTRIBUTIONS COMMITTEE
I, (name)_________________________________, hereby authorize my employer, _________________________________ to deduct from any wages earned or to be earned by me, the sum of $ ________ per month from my check to forward the said amount as an assignment and deduction to the TWU Political Contributions Committee, 1700 Broadway, 2nd Fl., New York, NY 10019.
The authorization, assignment and direction is intended to facilitate my transfer of this amount to the TWU Political Contributions Committee and to save me the time and effort of making a separate payment.
This authorization for, and contribution to, the TWU Political Contributions Committee is entirely voluntary on my part and has not been obtained by physical force, job discrimination, or financial reprisal or threat thereof, but is purely a voluntary contribution on my part made of my own free will and choice. I understand that contributions or gifts to the TWU Political Contributions Committee are not deductible for federal income tax purposes.
This assignment, authorization and direction may be revoked or cancelled by me at any time by writing to my employer. I direct, however, that this authorization shall be effective and apply to each payroll voucher I receive in each calendar year from my employer.
Employee # ________________________
NAME OF EMPLOYEE ___________________________________
Last, First, Middle
SIGNATURE OF EMPLOYEE ___________________________________
LOCAL# __________________________
ADDRESS ____________________________________________
_____________________________________________________
City, State, Zip Code
SS # _____________________________
NOTE: This form must be given to your employer for processing and a copy sent to the TWU COPE Dept.
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