IUOE Local 70

International Union of Operating Engineers Local 70

2722 County Rd D East, White Bear Lake, MN 55110
Phone: (651) 646-4566 Fax: (651) 646-2858

AUTHORIZATION AGREEMENT FOR
PREAUTHORIZED MONTHLY DUES PAYMENTS

Essentia Casual Employees

I hereby authorize the International Union of Operating Engineers, Local 70 to initiate debit entries to my account listed below, at the Financial Institution named below, for the purpose of making payments on my monthly dues.

Social Security Number: *

I understand that if the payment due date falls on a weekend or holiday, the transaction will be initiated on the next banking business day.

Amount to be deducted for Dues (cannot be less than monthly min.) *

Date to be Deducted Each Month: *

Note: If you are a new member there will be an initiation payment of $40 collected on the first payment

Email Address (for payment receipts): *

TYPE OF ACCOUNT TO DEBIT: *

Account # to Debit or CC # *

"This authorization is to remain in full force and effect until IUOE 70 receives written notification from me of the intent to terminate this authorization which provides the International Union of Operating Engineers Local 70 a reasonable opportunity to process and honor said notice of Termination. Monthly dues will automatically adjust with Contract and International Increases."

Please be sure to continue mailing your monthly dues until you receive written confirmation that your automatic payment has been completed. This letter does not waive or change the monthly dues due date which is the FIRST DAY OF EACH MONTH.

NOTE: THIS FORM MUST BE RECEIVED AND PROCESSED BEFORE PREAUTHORIZATION PAYMENTS BEGIN

Full Name *

Signature *

Use your mouse, finger, or touch device to write your signature.

Date *

Address *

City *

State *

Zip *

Employee Number: *

Returned auto drafts will incur a $25.00 Service Fee

* Required Fields

(IUOE Local 70 Authorization Agreement for Preauthorized Monthly Dues Payments for Essentia Health – SMDC Service - Casuals Continued)