Federation of Nurses/UFT
Local 2 American Federation of Teachers, AFL-CIO
52 Broadway NY, NY 10004 212 420-7981
Pursuant to applicable law, I assign to the Federation of Nurses/UFT from my compensation as an employee of Staten Island University Hospital (hereinafter called "my Employer") $……… or such different amount as the Federation of Nurses UFT and I authorize, and direct my Employer to withhold this sum from the compensation due me each month and remit it to the Federation of Nurses UFT.
I submit this assignment and authorization with the understanding that it will be effective and irrevocable for a period of one year from this date or up to the termination date of the current Collective Bargaining Agreement between my Employer and the Federation of Nurses UFT, whichever occurs sooner.
This authorization and assignment shall continue in full force and effect for yearly periods beyond the irrevocable period set forth above and each subsequent yearly period shall be similarly irrevocable unless revoked by me within the 30 day period preceding expiration of such irrevocable period. Such revocation shall be effected by simultaneous written notice by registered or certified mail to my Employer and the Federation of Nurses UFT which must be delivered within such 30-day period.
The assignment and authorization are effective at once.
Date Employee Signature