APPENDIX F
INSURANCE DEDUCTION AUTHORIZATION
Last Name First Ml.
Effective Date Social Security Number.
Address
School
Amount to be deducted each pay-period: $
To the Board of Education:
| hereby authorize you, according to arrangements agreed upon with the Nashua Teachers' Union, Local 1044, AFT,
NHFT, AFL-CIO, to deduct from my salary and transmit to said organization, monies for insurance premiums. |
hereby waive all right and claim to said monies so deducted and transmitted in accordance with this authorization,
and relieve the Board of Education and all its officers from any liability therefore. This authority shall remain in full
force and effect for all purposes while | am employed in this school system, or until revoked by me in writing or
modified through the issuance of another authorization between September 1st and September 15th of any given
year or at such time as a qualifying event including but not limited to an effective date of retirement, termination or
resignation.
Member Signature: Date:
STATUS: Part-Time Continuing Sub
Title | Regular (contract)
Federally Funded School Nurse
School Psychologist
Return this form to:
Nashua Teachers' Union
7C Taggart Dr.
Nashua, NH 03060
40
