TWU Local 525

AUTHORIZATION AGREEMENT FOR DUES PAYMENT

(Canaveral Port Authority Only)

I hereby authorize Transport Workers Union, Local 525, hereinafter called the Union, to initiate electronic debit entries (ACH) to my Checking or Savings account indicated below and the depository financial institution named below, hereinafter called Bank, to automatically debit my bank account in the amount of two (2) pay hours per month as my union dues on or around the 10th day of each month.

Hourly Rate *

x's 2 =

(dues per month). *

Note: I approved changes to the rate above whenever a raise or deduction in my hourly rate occurs.

First Name *

Last Name *

Signature *

Use your mouse, finger, or touch device to write your signature.

Date *

Employer's Name *

ACH PAYMENT AUTHORIZATION

Bank Name *

ACH / Routing Number (nine digits) *

Type of Account *

Account Number *

Note: This authorization will remain active and in effect until the Union receives written notification from you requesting termination of your dues payment.