Common use of AUTHORIZATION FOR PAYROLL DEDUCTION Clause in Contracts

AUTHORIZATION FOR PAYROLL DEDUCTION. City of Memphis, Tennessee BY: (Please Print) Last Name First Social Security Number ADDRESS: Number/Street City Zip Telephone I, the undersigned, hereby designate the Memphis Police Association as my duly chosen and authorized representative on matters relating to my- employment, subject to the provisions of the current agreement between the City of Memphis and the Memphis Police Association I hereby authorize and direct the City of Memphis to deduct from my earnings, each payroll, the following: _ DUES - The regular dues of the Memphis Police Association _ PAC- Contribution to the MPA’s Political Action Committee _ Memphis Police Association Charitable Foundation, Inc. Please ▇▇▇▇ appropriate box(es) SUPPLEMENTAL LIFE INSURANCE _ $20.00 _ $50.00 DENTAL AND VISION INSURANCE _ Single _ Employee +1 _ Family The amounts to be so deducted shall be certified to the City of Memphis by the Secretary-Treasurer of the Memphis Police Association and shall be remitted as such by the City. This authorization may be terminated by me by giving thirty (30) days written notice to the City of Memphis, Director of Human Resources and to the Secretary- Treasurer of the Memphis Police Association. Date Signature IBM# Email Address:

AUTHORIZATION FOR PAYROLL DEDUCTION. City of Memphis, Tennessee BY: (Please Print) Last Name First Social Security Number ADDRESS: Number/Street City Zip Telephone I, the undersigned, hereby designate the Memphis Police Association as my duly chosen and authorized representative on matters relating to my- employment, subject to the provisions of the current agreement between the City of Memphis and the Memphis Police Association I hereby authorize and direct the City of Memphis to deduct from my earnings, each payroll, the following: _ DUES - The regular dues of the Memphis Police Association _ PAC- Contribution to the MPA’s Political Action Committee _ Memphis Police Association Charitable Foundation, Inc. Please ▇▇▇▇ appropriate box(es) SUPPLEMENTAL LIFE INSURANCE _ $20.00 _ $50.00 DENTAL AND VISION INSURANCE _ Single _ Employee +1 _ Family The amounts to be so deducted shall be certified to the City of Memphis by the Secretary-Secretary- Treasurer of the Memphis Police Association and shall be remitted as such by the City. This authorization may be terminated by me by giving thirty (30) days written notice to the City of Memphis, Director of Human Resources and to the Secretary- Secretary-Treasurer of the Memphis Police Association. Date Signature IBM# Email Address:

AUTHORIZATION FOR PAYROLL DEDUCTION. City of Memphis, Tennessee BY: (Please Print) Last Name First Social Security Number ADDRESS: Number/Street City Zip Telephone I, the undersigned, hereby designate the Memphis Police Association as my duly chosen and authorized representative on matters relating to my- employment, subject to the provisions of the current agreement between the City of Memphis and the Memphis Police Association I hereby authorize and direct the City of Memphis to deduct from my earnings, each payroll, the following: _  DUES - The regular dues of the Memphis Police Association _  PAC- Contribution to the MPA’s Political Action Committee _  Memphis Police Association Charitable Foundation, Inc. Please ▇▇▇▇ appropriate box(es) SUPPLEMENTAL LIFE INSURANCE _  $20.00 _  $50.00 DENTAL AND VISION INSURANCE _  Single _  Employee +1 _  Family The amounts to be so deducted shall be certified to the City of Memphis by the Secretary-Secretary- Treasurer of the Memphis Police Association and shall be remitted as such by the City. This authorization may be terminated by me by giving thirty (30) days written notice to the City of Memphis, Director of Human Resources and to the Secretary- Secretary-Treasurer of the Memphis Police Association. Date Signature IBM# Email Address: