Membership Enrollment Form and Payroll Deduction

AUTHORIZATION FOR VOLUNTARY PAYROLL DEDUCTION
Name

First NameMiddle NameLast Name
Work Location
School Code Number
Position
Employee ID#
Commencing

MonthDayYear
Date
I hereby, authorize the School District of Philadelphia to withhold from my salary a sum equal to the constitutional dues of the Philadelphia Federation of Teachers, Local 3. I further authorize the School District of Philadelphia to withhold from my periodic pay, and pay in such periodic installments, my dues (and assessments if any) to the Philadelphia Federation of Teachers. This authorization shall remain in effect until further notice to the School District of Philadelphia and the Philadelphia Federation of teachers.
Signature

Clear
Date

MonthDayYear
Date
MEMBERSHIP ENROLLMENT FORM
The Philadelphia Federation of Teachers, 1816 Chestnut Street — Philadelphia, PA 19103 — 215-587-6738 — www.pft.org
Name

First NameMiddle NameLast Name
Sex

MaleFemale
Subject/Position
Employee ID#
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Work Location
Personal E-Mail Address
example@example.com
Signature

Clear
Date

MonthDayYear
Date
"The PFT CSPE Political Action Committee does not ask for or accept authorization from any candidate or political committee, and no candidate or political committee is responsible for its operation."

Authorization Form For Contribution to PFT Committee to support public education
I hereby authorize The School District of Philadelphia to deduct (check one)

$3.00$5.00$7.00$10.00
from my earnings each pay period the amount certified above as a voluntary contribution to be paid to the PFT Committee to Support Public Education, Philadelphia Federation of Teachers, Local 3, AFT. AFL-CIO, 1816 Chestnut Street, Philadelphia, Pennsylvania 19103, affiliated with the AFT/COPE Committee to be used in accordance with the by-laws of the PFT Committee to Support Public Education for the purpose of making political contributions. My contribution is voluntary and I understand that it is not required as a condition of membership in any organization, or as a condition of continued employment, and is free of reprisals, and that I may revoke this authorization at any time by giving written notice to the PFT Committee to Support Education. I understand that contributions to the PFT Committee to Support Public Education are not deductìble as a charitable contribution for federal income tax purposes
Should be Empty:

AUTHORIZATION FOR VOLUNTARY PAYROLL DEDUCTION

MEMBERSHIP ENROLLMENT FORM