APPENDIX #A:
FILL BOXES MARKED WITH AN (X)
REQUEST AND AUTHORIZATION FOR VOLUNTARY ALLOTMENT OF COMPENSATION FOR
PAYMENT OF EMPLOYEE ORGANIZATION DUES AND REQUEST THE UNITED FEDERATION OF
POLICE OFFICERS’ TO ACT AS MY EXCLUSIVE COLLECTIVE BARGAINING AGENT
NAME OF EMPLOYEE (Print Last Name, First, Middle) IDENTIFICATION NO. (Soc. Sec. or Other)
HOME ADDRESS (Street and Number} CITY AND STATE ZIP CODE
PHONE DEPARTMENT Nashua Police Department Professional Emplovees
NAME OF EMPLOYEE ORGANIZATION
UNITED FEDERATION OF POLICE OFFICERS’ LOCAL __ 645
[ ] t hereby certify that the regular dues of United Federation of Police Officers’ for the above
named member are currently established at $ (see union rep for cost) per week.
(X) (X)
SIGNATURE AND TITLE OF AUTHORIZED OFFICE (President or Treasurer) DATE
| 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 SUGH 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 DEOUCTED 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 0384
50
