BTU-C.O.P.E Form

Deduction Authorization: Baltimore Teachers Union-Committee on Political Education (C.O.P.E.)

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First Name *

Middle Name

Last Name *

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Mailing Country *

Mailing Address *

Mailing Suite

Mailing City *

Mailing State *

Mailing Zip Code *

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Home Phone

Mobile Phone

Preferred Phones

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Personal E-mail *

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Employee ID Number *

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Work Location Number *

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Dues Amount

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Total draft

COPE Amount

Other Amount

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Authorize COPE

I have read and agree to make the voluntary COPE contributions described below.

COPE DISCLOSURE: I hereby authorize a monthly contribution to the COPE in the amount indicated above. This authorization is signed freely and voluntarily and not out of any fear of reprisal, and I will not be favored nor disadvantaged because I exercise this right. I understand this money will be used to make political contributions. COPE may engage in joint fundraising efforts with AFT COPE and/or the AFL‐CIO. This voluntary authorization may be revoked at any time by notifying COPE in writing of the desire to do so. Contribution or gifts to COPE are not deductible as charitable contributions for federal income tax purposes. Contributions cannot be reimbursed or otherwise paid by any other person or entity.

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