(Please
print)
Name:__________________________________________________________________
Home Address:______________________________City:______________Zip:_____
Campus:_______________Office Phone:____________Home Phone:_____________
Home E-mail Address:___________________________________________________
AZ Legislative
District:_______________________________________________
(If unknown,
please indicate nearest crossroads/directions to residence. Example:
West
of
Priest, North
of Broadway)
| A. Membership
(check one) _____Probationary_____Year _____Appointive _____Retired/Part-Time Residential Faculty (Part-Time Residential Faculty are defined as Residential Faculty holding 50%-74% contracts.) |
B. Payment
Method (check one) _____Check (Make payable to MCCCD Faculty Association) _____Payroll Deduction (fill out and sign form below) |
| One-Year-Only and One-Semester-Only faculty members are not eligible for membership. | |
| C. Dues
Amount (check one) _____($275 appointive/probationary) _____($137.50 retired/prorated) |
|
Signature:____________________________________________Date:_____________
PAYROLL DEDUCTION AUTHORIZATION FORM
This
signature
authorizes my employer to deduct my membership dues in the amount
of $275 (or
$137.50
if retiree) in terms of established payroll deduction procedure.
Distribution:
$250 to District - $25 to the local senate ($125/$12.50 for retirees).
Members who
pledge
or pay in full by November 15 are entitled to access (as
determined by
the Executive Committee) to the Faculty Association attorney for
school-related
matters. In addition, the Executive Council allocates representatives
to colleges
based
on the number of faculty who pledge or pay dues by November 15.
• I
AUTHORIZE
THE DEDUCTION OF $ __________ PER YEAR TO THE FACULTY ASSOCIATION.
BY SIGNING
BELOW,
I AGREE TO PAY THIS AMOUNT BY MAY 30TH OF NEXT YEAR.
•
MEMBERSHIP
WILL BE RENEWED ANNUALLY AND PAYROLL DEDUCTION WILL CONTINUE FROM
YEAR TO YEAR
UNLESS A MEMBER SUBMITS A CANCELLATION REQUEST IN WRITING TO THE
PAYROLL
DEPARTMENT.
•
WITHOUT
A SIGNATURE OF AUTHORIZATION, PAYROLL CANNOT PROCESS YOUR REQUEST.
Signature:____________________Employee ID #:__________Date:________
RETURN ENTIRE FORM/CHECK PAYMENT TO YOUR LOCAL SENATE TREASURER!