IF YOU WISH YOUR DUES TO BE DEDUCTED DIRECTLY 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 BY MAIL OR FAX.

AUTHORIZATION FOR DEDUCTION OF GUILD DUES

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.

Full-time Regular ($27.50 per month) plus Initiation Fee $300.00 ($100 per month)	___________
Part-time Regular ($27.50 per month) plus Initiation Fee $300.00 ($100 per month)	___________
Short Hour ($27.50/month) plus Initiation Fee $300.00 ($100 per month)	___________
Graduate Intern ($27.50 per month) plus Initiation Fee $300.00 ($100 per month)	___________
On-Call ($20.00 per month) plus Initiation Fee $300.00 ($100 per month)	___________

RETURN THE COMPLETED FORM TO 
THE HUMAN RESOURCE SERVICE CENTER

ATTN: OSCAR PENA, at HRSC
FAX 877- 477-2329

KAISER  NORTH  DUES CK-OFF FORM 7-19-07