Support the Union's Committee on Political Education! AFT Local Union Name (hereafter referred to as "The Local") Local Number First Name Last Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Job Title Work Location Contact Information Non-Work Phone Non-Work Email Work Phone Home Address Street / P.O. Box City State ZIP Committee On Political Education SUPPORT THE UNION’S COMMITTEE ON POLITICAL EDUCATION I hereby authorize my employer to deduct from my salary the sum indicated below (contribution choices will appear after you check the authorization box at the front of this text) per pay period and forward that amount to The Local's Committee On Political Action (COPE). This authorization is signed freely and voluntarily and not out of any fear of reprisal, and I will not be favored or disadvantaged because I exercise this right. I understand this money will be used by AFT/COPE to make political contributions. AFT/COPE may engage in joint fundraising efforts with the AFL-CIO. This voluntary authorization may be revoked at any time by notifying The Local's COPE in writing of the desire to do so. Contributions or gifts to AFT/COPE are not deductible as charitable contributions for federal income tax purposes. Authorized COPE Contribution * $10 $15 $25 Other If "Other", Please Specify: * Signature * Clear signature Date of signature * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Leave this field blank
