I hereby make application for membership in the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION and affirm that the statements made are true, and I agree that all moneys paid by me shall be forfeited and my membership declared void if they are not true. I authorize the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION to represent me for the purposes of collective bargaining and handling of grievances, either directly or through such local union as it may duly designate.

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By providing your E-MAIL you are authorizing UFCW Local 75 to communicate via electronic mail. By agreeing to accept email communication, I understand that I am also authorizing UFCW Local 75 to retain my email address in its databases so that it may send me future communications. I acknowledge and understand that email messages sent to me are not encrypted and travel over the Internet, resulting in a risk that any email will be intercepted and read by third parties to whom the e-mail is not directed. I hereby assume the foregoing risk.

I authorize any employer for which I work, that has a contract with UFCW, to deduct from my wages an amount equivalent to dues and initiation and other fees as certified by the President or Secretary-Treasurer (or designee) of UFCW Local 75. This authorization is voluntarily made in consideration for the cost of representation, collective bargaining, and other activities the Union undertakes for me and is not contingent upon my continued union membership. The UFCW is authorized to transfer this authorization to any company in the event I change my employment. This authorization shall be irrevocable for a period of one year from the date of execution thereof or until the termination of the collective bargaining agreement between the company for which I work and the Union, whichever occurs sooner, and from year to year thereafter, unless not fewer than 30 days and not more than 45 days prior to the end of any subsequent yearly period or to the termination of the collective bargaining agreement, respectively, I give the Union written notice (via certified mail, return receipt requested) of revocation bearing my signature thereon.

I hereby authorize my employer to deduct an amount equivalent to twenty-five (25¢), fifty cents (50¢), seventy-five cents (75¢), one dollar ($1.00), or other amount as indicated below per week from my paycheck. Such amount is to be transmitted to the UFCW International Active Ballot Club at such time and in such manner as may be agreed upon.

I understand that this authorization is voluntarily made and that the amount suggested as a contribution is a guideline and that I may contribute more or less than this amount by any lawful means, other than this checkoff, or may refuse to contribute, and that the making of payments to the UFCW Active Ballot Club is not a condition of membership in the Union or of employment with the employer and that I have a right to refuse to sign this authorization and not to contribute to the UFCW ABC without reprisal. I understand that my contribution will be used for political purposes, including the support of candidates for federal, state and local office. I expressly reserve the right to revoke at any time this authorization in writing.