Join the Faculty Association at UCSF

I wish to join the UCSF FA. I agree to pay the following dues (check one) by payroll deduction and to sign Form U669 below or by personal check. (FA dues are tax deductible: either on Schedule A of your income tax to the extent that they and other profession-related and income-producing expenses exceed 2% of your adjusted gross income; or in some instances on Schedule C without the 2% limitation. Please check with your tax consultant.)
$8.00 per/mo for Assist. Profs and Acting Profs of Law
$10.00 per /mo for Associate Professors
$14.00 per/ mo for Professors
Mail Completed Forms to:
UCSF Faculty Association
915 Cole Street #373
San Francisco, CA 94117

My complete mailing address for the membership list is:
Name
UCSF Campus Box Number
Department
Street Address

PhoneFAX
E-mail
Employee Organization Membership Payroll Deduction Authorization UPAY 669 (10/80)
Last Name
First Name
Middle Initial
Department Employed at UC
Title at UC
Organization name: Faculty Association at UCSC CampusUCSC
Employee ID
DateAction on this Form to Become Effective on the Pay Period
Beginning
Monthly Deduction:
Dues
Initiation Fees 0
General Assessment 0

I authorize the Regents of the University of California to withhold monthly or cease withholding from my earnings as an employee, membership dues, initiation fees, and general assessment as indicated above.

I understand and agree to the arrangement whereby one total monthly deduction will be made by the University based upon the current rate of dues, initiation fees, and general assessments.

I also understand that changes in the rate of dues, initiation fees and general assessments may be made after notice to that effect is given to the University by the organization to which such authorized deductions are assigned and hereby expressly agree that pursuant to such notice the University may withhold from my earnings amounts either greater than or less than those shown above without obligation to inform me before doing so or to seek additional authorization from me for such withholdings.

The University will remit the amount deducted to the official designated by the organization. This authorization shall remain in effect until revoked by me allowing up to 30 days time to change the payroll records in order to make effective this assignment or revocation thereof or until another employee organization becomes my exclusive representative.

It is understood that this authorization shall become void in the event the employee organization's eligibility for payroll deduction terminates for any reason. Upon termination of my employment with the University, this authorization will no longer be in effect. This authorization does not include dues, initiation fees and general assessments to cover any time prior to the payroll period in which the initial deduction is made. Payroll deductions including those legally required and those authorized by an employee are assigned priorities. In the event there are insufficient earnings to cover all required and authorized deductions, it is understood that deductions will be taken in the order assigned by the University and no adjustment will be made in a subsequent pay period for membership dues, initiation fees and general assessments.

Employee Signature
Date
For University Use Only
Tran Code_______
Employee ID No________
Date_____________
Element No._______
Bal CD___________
Amount________