1. Complete the fields
2. Print form in browser
3. Sign and date form
4. Mail form to UPEA
Last Name |
First Name |
MI |
Employer (Agency, Department, District, Division, etc.) |
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| Home Mailing Address |
Home Telephone |
Employer Address |
Work Phone |
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| City |
State |
Zip |
City |
State |
Zip |
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| Home Email:
Work Email: |
Voting Precinct |
Senate District |
House District |
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| I hereby voluntarily authorize and direct my employer to deduct $15.00 per month from my paycheck and pay the same to the Utah Public Employees’ Association (UPEA) as dues for membership in that organization and agree that said payroll deductions shall continue until I revoke this authorization by giving written notice to UPEA. Authorization for withholding UPEA dues will remain in effect even after retirement unless a member gives written notice to UPEA. Upon retirement this form authorizes the Utah Retirement Systems to deduct $5.00 per month from my retirement allowance. This payroll deduction authorization shall serve as my application for membership in UPEA and shall designate UPEA as my employee representative for all purposes provided by law. |
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| Signature: | Date: |
Referred By: | Renewal Month for Auto Insurance |
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For Office Use Only |
District # |
Chapter # |
Jurisdiction # |
Low Org./Dept No. |
Confirmed Date |
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Print and Mail To:
UPEA
1000 West Bellwood Lane
Murray, UT 84123