Loudoun

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I hereby request and voluntarily accept membership in the Loudoun Chapter of SEIU VA 512 (“Loudoun Chapter”). This means I will receive the benefits and abide by the obligations of membership set forth in the Constitutions and Bylaws of the Loudoun Chapter, SEIU VA 512 and the Service Employees International Union (“SEIU”). I authorize the Loudoun Chapter to act as my representative in bargaining over matters relating to my economic welfare, and as my exclusive representative where authorized by law. I know that membership in the union is voluntary and is not a condition of my employment, and that I can decline to join without reprisal.

I request and voluntarily authorize my employer, Loudoun County Government, to deduct from my earnings and payable to SEIU VA 512 an amount equal to the regular dues uniformly applicable to members of Loudoun Chapter of SEIU VA 512 (currently $10 per pay period, but subject to change per a membership vote and in accordance with Loudoun Chapter’s Constitution and Bylaws. This authorization shall remain in effect unless I revoke it by sending written notice via U.S. mail. This authorization shall and shall remain in effect until such time as it is amended or rescinded by me in writing. My authorization is voluntary and is not a condition of my employment, and I can decline to agree to it without reprisal.

Contributions or gifts to SEIU Virginia 512 are not tax deductible as charitable contributions for Federal income tax purposes. However, they may be tax deductible under other provisions of the Internal Revenue Code.