4933 Rio Rancho School Employees Union Local 4933 Online Membership Form

I hereby authorize payroll deduction from my salary for the payment of dues as set by the local union. This authorization remains in effect until I provide written notice to the Union during the annual 10-day revocation period, which is identified in the collective bargaining agreement. I understand that my dues will include the many services and benefits of local, state, and national AFT bodies. Union dues may not be deductible for federal income tax purposes; however, under limited circumstances dues may qualify as a business expense. AUTHORIZATION FOR STATE COPE I hereby authorize the Union to forward $1 per month of my current dues payment to the AFT New Mexico Committee on Political Education. I understand that I may opt out of this authorization at any time by notifying the Union in writing and that this assessment will revert to the organizing assessment fund. I understand that this authorization does not increase my dues. ACTIVATE $5,000 OF GROUP LIFE INSURANCE AT NO COST TO YOU If elected, the $5,000 of Group Term Life Insurance is available to me at no cost for one full year as a new AFT member. I want to be covered under the group plan for the benefits which I am or may become eligible for, as requested below. The AFT provides this insurance for one year as a benefit of AFT membership. After one year, I will be invited to continue the insurance. I hereby certify that all statements and answers in this form are full, complete, and true to the best of my knowledge and belief. I understand that to be eligible for coverage I must be a new AFT member, and not currently insured under the Group Term Life Insurance plan for AFT members. I understand that my coverage will become effective on the first day of the month following the date this application is signed. The premiums for this insurance are being paid by AFT only for one year from the effective date. Any person who knowingly and with intent to defraud any insurance company or other person files an AFT application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which may be a crime and may be subject such person to criminal and civil penalties. For questions, phone toll-free (888) 423-8700 or visit www.aftbenefits.org.

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.