IBEW-COPE Check-Off Authorization

Name *

First

Last

Date *

Last 4 of SSN (Please - only last 4) *

IBEW Local No. *

Electronic Signature - Type Your Name *

Amount *

Consent *

I hereby authorize the company to deduct from any pay the amount indicated above for each pay period worked and to forward that amount to the International Brotherhood of Electrical Workers, Committee on Political Education. This authorization is given voluntarily and not out of any fear of reprisal and on the understanding that IBEW-COPE is engaged in a joint fund raising effort with the AFL-CIO, will use the money contributed to that effort to make political contributions and expenditures in connection with federal and state elections, and that this voluntary authoriztion may be revoked at anytime by notifying the company in writing of a desire to do so. Contributions or gifts to IBEW-COPE are not deductible as charitable contributions for federal income tax purposes.