Authorization for Payroll Deduction
Albuquerque TVI Employees Federation
Local #4974 7621 Mountain Rd NE Albuquerque, NM 87110

Name ____________________________________ Work Phone _________________

Address ___________________________________ Home Phone_________________

City _________________________ Zip __________ E-Mail ______________________

Department (if applicable)  _______________________
Job Title: Check One
         ___ full time faculty                               ___ part time faculty
         ___ full time instructional tech/tutor      ___ part time instructional tech/tutor
         ___ full time security                              ___ part time security
         ___ reader/writer

 Current Dues Amounts ( Per pay period for 24 pay periods per year ) Check one:
         ___ Earning starting full time faculty salary or more:  $ 18.94
         ___ Earning $10,000 a year to starting full time faculty salary:  $ 9.72
         ___ Earning less than $10,000 a year:  $ 6.02

I hereby authorize TVI to deduct from the compensation due me the above amount per pay period for twenty-four (24) pay periods per year as Albuquerque TVI Employees Federation membership dues. I also authorize TVI to deduct from the compensation due me my membership dues as revised for the current year and each year thereafter. Dues deductions will continue unless revoked in writing by me to the Albuquerque TVI Employees Federation not later than 30 days prior to the proposed effective date of revocation.

Signature___________________________________ SS#_________________________ Date______________
Dues paid to the Albuquerque TVI Employees Federation may not be deducted for Federal Income Tax purposes, however under limited circumstances may qualify as a business expense.

Your Union is Stronger with COPE!
I hereby authorize TVI to deduct from compensation due me $1.00 per pay period for twenty-four (24) pay periods per year. This authorization is signed freely and not out of fear of reprisal and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used by Albuquerque TVI Employees Federation/COPE to make political contributions. Albuquerque TVI Employees Federation may engage in joint fund raising efforts with the AFL-CIO. This voluntary authorization may be revoked at any time by notiyfing Albuquerque TVI Employees Federation/COPE in writing.

Signature________________________________________  Date ______________
Contributions to Albuquerque TVI Employees Federation/COPE are not deductible as charitable contribution for Federal Income Tax purposes.

Return completed form to:
Scott Henriksen
Trades, Main Campus
TVI Community College
Albuquerque, NM  87106

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