FINANCE DEPARTMENT

ATTN: Payroll Unit

16000 N Civic Center Dr
Surprise, AZ 85374
Ph: 623-222-1800
Fax: 623-222-1801
TTY: 623-222-1002

Employee Organization Dues Approval & Authorization Form

I hereby approve and authorize the City of Surprise to deduct certified employee
organization dues from my biweekly wages and to remit those dues to the following
organization.

Surprise Police Employee Association

The amount of the dues to be deducted is set forth below:

Surprise Police Account Name/# Amount

Employee
Surprise Police Employee Association / 9986 $15.00
Association

Deductions will commence during the first full payroll period following my completion
and submission of this Approval and Authorization.

This Approval and Authorization may be revoked at any time by giving notice of
revocation to the City in writing.

This Approval and Authorization revokes any prior dues deduction authorizations.

This Approval and Authorization will expire on December 31 st. (A new form must be
completed every calendar year.)

The City will incur no liability by honoring this authorization.

______________________________ _______________________________
Employee Printed Name Employee Signature Date

Note: Please keep a copy of this authorization for your records.