Dues Deduction

Dues Deduction Form

REQUEST AND AUTHORIZATION FOR VOLUNTRY ALLOTMENT OF
COMPENSATION FOR PAYMENT OF EMPLOYEE ORGANIZATION DUES AND
REQUEST THE NEW ENGLAND POLICE BENEVOLENT ASSOCIATION TO
ACT AS MY EXCLUSIVE COLLECTIVE BARGAINING AGENT

Employee Information

First NameMiddle NameLast NameSuffix

Social Security Number

Cell PhoneWork Phone (Optional)

Personal Email AddressHome Address (Street & Number)

CityStateZip Code

Organization

Organization NameNEPBA Local #

Dues Frequency

Weekly

Bi‑weekly

Monthly

Amount

Select all that apply

I hereby certify that the regular dues of New England PBA for the above named member. I acknowledge I may withdraw from the Union only during the month of July of each year and with written notice to the Union and the City/Town.

I hereby certify that the employee listed above wishes to not be a dues paying member of New England PBA and acknowledges any individual need for Union services shall be required to pay an hourly rate which shall be determined by the Executive Committee.

Electronic Signature

By selecting the "Send" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual and/or handwritten signature on this Agreement. By selecting "Send" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.

Signature NameSignature Date

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