I hereby make application for membership in the UNITED FOOD & COMMERCIAL WORKERS INTERNATIONAL UNION and affirm that the above statements are true, and I agree that all moneys paid by me shall be forfeited and my membership declined void if they are not true. I authorize the UNITED FOOD AND COMMERCIAL WORKERS INTERNATIONAL UNION to represent me for the purposes of collective bargaining and handling of grievances either directly or through such local union as it may duly designate.

You are hereby authorized and directed to deduct from my wages, commencing with the next payroll period, an amount equivalent to dues and initiation fees as shall be certified by the Secretary-Treasurer of Local 455 of the United Food and Commercial Workers International Union and remit same to said Secretary-Treasurer. This authorization and assignment is voluntarily made in consideration for the cost of representation and collective bargaining and is not contingent upon my present or future membership in the Union. This authorization and assignment shall be irrevocable for a period of one (1) year from the date of execution or until the termination date of the agreement between the Employer and Local 455, whichever occurs sooner, and from year to year thereafter, unless not less than thirty (30) days and not more than forty-five (45) days prior to the end of any subsequent yearly period or bargaining agreement termination date, or when an agreement is not in effect, I give the Employer and Union written notice of revocation bearing my signature thereto. Written notice must be sent by mail to 121 Northpoint Dr., Houston, TX 77060 and, received during the window period. The Secretary-Treasurer of Local 455 is authorized to deposit this authorization with my Employer and further this authorization will remain effective if my employment with my Employer is terminated and I am later re-employed by the same Employer under contract with Local 455.

I hereby authorize my Employer to deduct from my paycheck the sum of $0.50 weekly, such amount to be transmitted to the UFCW International Active Ballot Club at such time and in such manner as may be agreed upon by my Employer and Local Union. I understand that this authorization is voluntarily made and that the amount suggested as a contribution is a guideline and that I may contribute more or less than this amount by any lawful means, other than this check-off, or may refuse to contribute, and that making of payments to the UFCW Active Ballot Club is not a condition of membership in the Union or of employment with the Employer and that I have a right to refuse to sign this authorization and not to contribute to the UFCW Active Ballot Club without reprisal. I also understand that my contribution will be used for political purposes, including the support of candidates for Federal, State and Local office. I expressly reserve the right to revoke at any time this authorization in writing.