Form No. 107
* Mandatory Fields
**Submission of this information is voluntary, will be kept confidential and will be used in accordance with the provisions of applicable federal laws that may require the information to be summarized and reported to the federal government. If you choose not to self-identify, the federal government may require this information be determined by visual survey and/or other available information.
OBLIGATION OF I.B.E.W. ®
"I, the undersigned, in the presence of members of the International Brotherhood of Electrical Workers®, promise and agree to conform to and abide by the Constitution and laws of the I.B.E.W.® and its Local Unions. I will further the purposes for which the I.B.E.W.® is instituted. I will bear true allegiance to it and will not sacrifice its interest in any manner."
Authorization to Deduct Union Dues and Initiation Fees
hereby authorize and direct the Tennessee Valley Authority to deduct from my earnings and to remit to the union named below in accordance with TVA regulations for making payroll deductions amounts for dues which may include any or all the type dues such as initiation fees, regular monthly dues, working dues, field dues, and administrative dues.
I hereby appoint the said union and its authorized agents as my agents and attorneys in fact to receive from TVA said amounts in my behalf. I understand that TVA acts only as an agent for the collection and remittance of union dues and initiation fees; and in consideration of TVA’s performance of this service in my behalf, I hereby release TVA from all claims for damage or injury which may be attributable, in whole or in part, to negligence or mistake of TVA or its employees or agents in the collection and remittance of said dues and initiation fees. This authorization shall continue in effect until (1) termination of my employment with TVA, or (2) reclassification to a position under the jurisdiction of another international union; or (3) until revoked by me within the time period set out below by written notice to the appropriate TVA payroll office, with a copy thereof to the union. I understand that this authorization shall be irrevocable for a period of one year from the effective date of this original authorization and each annual renewal thereafter. I further understand that this authorization is automatically renewed annually unless TVA receives a written notice of revocation, with a copy to the union no more than 60 days before the annual anniversary date of the original authorization, and that this revocation will be effective for the month following the annual anniversary date or as soon as possible thereafter. TVA will accept cancellation only from the employee who signed the form.
Curtis Sharpe IBEW International Representative
International Brotherhood of Electrical Workers (IBEW)
325 Cherokee Boulevard
Chattanooga, TN 37405
Rev. October 1986
PRIVACY ACT STATEMENT
This information is collected under authority of the Tennessee Valley Authority Act of 1933, 48 Stat. 58 as amended, 16 U.S.C.§§ 831-831dd (1976; Supp. V, 1981). It will be used to process the appropriate payroll deduction as authorized by you. The information may also be disclosed in circumstances when disclosures of your payroll records would be appropriate. Your failure to provide the information could delay or prevent the processing of your deduction.