Dwolla

UE Local 896 COGS Union Dues *

Membership ( $ 27.39 for each month )

Total $ 0.00

NOTICE

Dues will be deducted from your bank account on the 1st of the month, beginning in the month following the submission of this form. To complete it, you will need to create a Dwolla account, which you may already have if you pay your vehicle registration online, for example.

Step One: First, visit https://www.dwolla.com/direct/register to create a Dwolla account.

Step Two: You will be prompted to verify your account information. Different financial institutions offer different ways of doing this. You may be asked to login with your username and password or provide your account and routing numbers and verify a deposit amount. Dwolla is similar to Venmo, PayPal, and other secure payment systems.

Step Three: After your Dwolla account is verified, you will need to return to this form to submit your membership to COGS.

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Personal Email (Not UIowa) *

example@example.com

Work Department

Office Number and Building

University ID #

Appointment Term

Fiscal Year (12 Months) Academic year (10 Months)

Membership Application and Dues Authorization

I hereby request and accept membership in UE Local 896 COGS and authorize it to represent me and in my behalf to negotiate and conclude all agreements as to hours of labor, wages, and all other conditions of employment.

I authorize and direct the Union to withdraw payment on the 1st of each month, while I am employed by the Employer in the Unit covered by the collective bargaining agreement, and irrespective of my membership status in the Union, an amount equal to UE membership dues, and an initiation fee as designated by the Union and to promptly remit the same to UE Local 896, United Electrical, Radio & Machine Workers of America (UE). I understand that membership and the periodic payment of dues are not a condition of employment.

This assignment and authorization shall continue until revoked and cannot be revoked for a period of one (1) year from the date appearing above or until the expiration date of the current collective bargaining agreement between the Employer and the Union, whichever comes sooner, and shall be irrevocable for each succeeding year thereafter unless it is revoked by me within the ten (10) days preceding the end of any such period of irrevocability. Such notice of revocation shall become effective respecting the dues for the month following the month in which such written notice is given.

Revocation shall be effective only if I give UE Local 896, United Electrical, Radio & Machine Workers of America (UE) written notice and it is received or postmarked during the period specified above.

Signature *