HSA Enrollment Form

Full Name*

(Last Name, First Name)

Last Name

Job Title (Resident or Fellow)*

PGY - *

Employee I.D. Number (can be found on your ID badge)

Department*

Personal Telephone Number*

Personal Email*

example@example.com

Street Address*

City*

State (IL, WI, IN, etc.)*

Zip Code*

Effective immediately, I hereby voluntarily authorize and direct my Employer to deduct from my pay each pay period, for a total of twenty-four (24) pay periods per year, regardless of whether I am or remain a member of the Union, dues in the amount established by the Union, or an amount that the Union may adjust periodically. I further authorize my Employer to remit such amount monthly to the Union.

This voluntary authorization and assignment shall be irrevocable, regardless of whether I am or remain a member of the Union, for a period of one (1) year from the date of execution, and for year to year thereafter, unless I give the Employer and the Union written notice of revocation between the period of June 1 through June 30 (inclusive) of any given year; provided however, if the applicable collective bargaining agreement specifies a longer annual revocation period, then only that longer period shall apply. The applicable collective bargaining agreement is available for review, upon request. This card supersedes any prior checkoff authorization card I signed.

Employee Signature*

Date*

Date