Union Dues Withdrawal Request Form
Submit your request to authorize the withdrawal of union dues from your account or paycheck. Please complete all required fields for processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Union Name
*
Union Membership Number
*
Employer Name
*
Department or Work Location
Preferred Method of Dues Withdrawal
*
Payroll Deduction
Direct Debit
Other
Amount to be Withdrawn (USD)
*
Withdrawal Frequency
*
Please Select
Weekly
Bi-Weekly
Monthly
Other
Start Date for Dues Withdrawal
*
-
Month
-
Day
Year
Date
Additional Notes or Special Instructions
Signature (Please sign to confirm your authorization)
*
Submit Request
Submit Request
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