Membership Enrollment Form and Payroll Deduction

AUTHORIZATION FOR VOLUNTARY PAYROLL DEDUCTION
Name (as it appears on your District ID)

First NameMiddle NameLast Name
Work Location
School/Location Code Number
Position
Employee ID# (Do not include leading zeros)
Commencing

MonthDayYear
Date
Effective immediately, I hereby voluntarily authorize and direct the School District of Philadelphia to deduct from my pay each pay period, regardless of whether I am or remain a member of the Philadelphia Federation of Teachers, the amount of dues certified by the Philadelphia Federation of Teachers and as they may be adjusted periodically by the Union. I further authorize the School District of Philadelphia to remit such amount to the Philadelphia Federation of Teachers. This voluntary authorization and assignment shall be irrevocable, regardless of whether I am or remain a member of the Philadelphia Federation of Teachers until the termination date of the collective bargaining agreement between the School District of Philadelphia and the Philadelphia Federation of Teachers for the years to come, unless I give the Union written notice of revocation during the fifteen (15) days before termination of the collective bargaining agreement. Membership will commence once dues deduction begins.

I recognize that my authorization of payroll deductions is voluntary and not a condition of my employment.

Payments to the Union are not deductible as charitable donations for federal income tax purposes. However, they may be deductible as ordinary and necessary business expenses.
Signature

Clear
Date

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

First NameMiddle NameLast Name
Sex

MaleFemale
Subject/Position
Employee ID# (Do not include leading zeros)
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
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$10.00Other
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