Local 22, I.a.t.s.e. Referral Fee Checkoff Authorization, Form W-4 - Employee'S Withholding Allowance Certificate - 2015 And Referral Fee Checkoff Authorization

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LOCAL 22, I.A.T.S.E.
REFERRAL FEE CHECKOFF AUTHORIZATION
To: _________________________________________ (Employer)
Date: ________________________
You are hereby authorized and directed to deduct three and one-half percent (3.5%) from my gross earnings as required by the collective
bargaining agreement between the Employer and Local 22, International Alliance of Theatrical Stage Employees and Moving Picture Machine
Operators of the United States and Canada, for Union referral services.
In addition, I authorize the Employer to remit such deduction to the Union on the date provided in the collective bargaining agreement for
such deduction. This authorization is made consistent with all terms of the National Labor Relations Act, As Amended. This referral fee does not
constitute the payment of Union Initiation fees or Union dues.
SIGNATURE: _____________________________________________________________________
Please Print the Following Information
FIRST NAME:_________________________ M.I. ______ LAST NAME: _________________________________
STREET: _____________________________________________________________________ APT. # __________
CITY: _______________________________________ STATE: ___________ ZIP: _________________________
HOME PHONE: ______________________ CELL: ______________________ OTHER: ___________________
E-MAIL ADDRESS: ____________________________________________________________________________
EMERGENCY CONTACT: ______________________________________________________________________
HOME PHONE: _______________________ CELL: ______________________ OTHER: ___________________

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