Membership Form

authorize University of Vermont Medical Center (“UVMMC”) to deduct from my gross salary, VFNHP, Local 5221, AFT Vermont (‘Local 5221’) uniform union membership dues (1% + $2.50 per pay period) consistent with the collective-bargaining agreement (the “Contract”), between UVMMC and Local 5221 and transmit the dues to the treasurer designated by Local 5221. The deductions shall be made in equal amounts according to UVMMC’s payroll system. Any future change in the uniform membership dues which is approved by the membership of Local 5221 as provided for in the constitution of VFNHP or its affiliates and is consistent with the Contract shall be applied automatically to my deductions.

I submit this authorization and assignment with the understanding that it will be irrevocable for a period of one year from this date or for the term of the Contract in effect on this date, whichever is earlier.

This authorization and assignment shall continue in full force and effect for yearly periods beyond the irrevocable period set forth above, and subsequent yearly periods shall be similarly irrevocable unless revoked by me in written form by registered mail return receipt requested to UVMMC with a copy to Local 5221, within thirty (30) calendar prior to the anniversary of my signing this agreement. The deduction of uniform dues under this authorization and assignment shall cease whenever there is no collective-bargaining agreement in effect between UVMMC and Local 5221.