[ | | hereby certify that the regular dues of United Federation of Police Officers’ for the above
named member are currently established at $ 44.00 (see union rep for cost) per week.
(X) (X)
SIGNATURE AND TITLE OF AUTHORIZED OFFICE (President or Treasurer) DATE
1 HEREBY AUTHORIZE THE ABOVE NAMED AGENT TO DEDUCT FROM MY PAY EACH PAY PERIOD, OR THE FIRST FULL PAY
PERIOD OF EACH MONTH THE AMOUNT CERTIFIED ABOVE AS THE REGULAR DUES AND TO REMIT SUCH AMOUNTS TO THE
NEW ENGLAND POLICE BENEVOLENT ASSOCIATION IN ACCORDANCE WITH ITS ARRANGEMENTS WITH MY EMPLOYING
AGENCY. | FURTHER AUTHORIZE ANY CHANGE IN THE AMOUNT TO BE DEDUCTED WHICH IS CERTIFIED BY THE ABOVE
NAMED EMPLOYEE ORGANIZATION AS A UNIFORM CHANGE IN ITS DUES STRUCTURE
(X) (X)
SIGNATURE OF EMPLOYEE DATE
* COPY SHOULD BE SENT TO: Treasurer, United Federation of Police Officers’, P.O. Box 97, Hampton, NH 03843
APPENDDCHR:
APPENDIX #€B:
UAW Profassional Employees-UFPO Local 645 Professional Employees of the Nashua Police
Department
DESIGNATION OF BENEFICIARY FORM
Date:
80
