GUILD FOR PROFESSIONAL PHARMACISTS
21243 Ventura Blvd., Suite 241
WOODLAND HILLS, CA 91364-2167
(877) 992-0475 TOLL FREE (818) 992-0475 GUILD FAX (818) 992-6835
E-MAIL: gfpp@aol.comAUTHORIZATION FOR DEDUCTION OF GUILD DUES
IF YOU WISH YOUR DUES TO BE DEDUCTED DIRELY FROM YOUR PAY CHECK AND FORWARDED TO THE GUILD BY KAISER, PLEASE FILL OUT THE REQUIRED INFORMATION BELOW AND RETURN THE COMPLETED FORM IMMEDIATELY TO THE GUILD.
I hereby authorize and direct my employer, Kaiser Permanente, to deduct from my pay beginning with the current pay period my regular periodic Guild dues as certified to the Company by the Treasurer of the Guild on account of membership dues in the Guild For Professional Pharmacists.
I submit this authorization and assignment with the understanding it will be effective and irrevocable for a period of one (1) year from this date, or within a fifteen (15) day period to the termination date of the current collective bargaining agreement between Kaiser Permanente and the Guild, whichever occurs sooner.
This authorization and assignment shall continue in full force and effect for yearly periods beyond the irrevocable period set forth above, and each subsequent yearly period shall be similarly irrevocable unless revoked by me within fifteen (15) calendar days prior to the date of termination of any irrevocable period hereof.
Signature ___________________________ Date ____________________
Print Name _________________________ Social Security # _______________
CHECK CORRECT STATUS.
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Full-time Regular ($27.50 per month) plus Initiation Fee $300.00 ($100 per month) |
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Part-time Regular ($27.50 per month) plus Initiation Fee $300.00 ($100 per month) |
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On-Call ($20.00 per month) plus Initiation Fee $300.00 ($100 per month) |
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Pharmacy Intern ($10.0 per month) |
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RETURN THE COMPLETED FORM TO THE HUMAN RESOURCE SERVICE CENTER
ATTN: OSCAR PENA, at HRSC
FAX 877- 477-2329
KAISER OREGON DUES CK-OFF FORM 7-19-07