Healthcare Leadership Fund Name* First Last Personal Email* Phone‡‡ By providing my phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my cellular phone on a periodic basis. SEIU Healthcare 1199NW and SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.Hospital/Clinic/Agency*Today's Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920State of Residence*SelectMontanaAny other state or territoryHold Politicians AccountableBecause decisions made by politicians in Helena and Washington D.C. affect healthcare funding and our jobs, SEIU members get involved to hold politicians accountable on our issues. Contributions to the SEIU Healthcare 1199NW Montana PAC are used to support elected officials who are committed to improving healthcare. Contributions to the SEIU Healthcare 1199NW Montana PAC are used to support elected officials who are committed to improving healthcare.I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Healthcare 1199NW Montana PAC.* $5.00 $7.00 $11.99 per pay period to be forwarded to SEIU Healthcare 1199NW. Contributions or gifts to SEIU Healthcare 1199NW Montana PAC are not tax deductible as charitable contributions.Signature Verification*This authorization is made voluntarily based on my specific understanding that (1) I am not required to sign this form or make voluntary SEIU Healthcare 1199NW Montana PAC contributions as a condition of my employment by my employer or membership in the union; (2) I may refuse to contribute without any reprisal; (3) I am a U.S. citizen or lawful Permanent Resident of the U.S. and a union member or executive/administrative staff member; (4) The amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer; (5) SEIU 1199NW Montana PAC uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU Healthcare 1199NW.Authorization* I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Healthcare 1199NW Montana PAC. Hold Politicians AccountableBecause decisions made by politicians in Olympia and Washington D.C. affect healthcare funding and our jobs, SEIU members get involved to hold politicians accountable on our issues. Contributions to the SEIU Committee On Political Education (COPE) are used to support elected officials who are committed to improving healthcare.I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Committee on Political Education (SEIU COPE).* $5.00 $7.00 $11.99 per pay period to be forwarded to SEIU Healthcare 1199NW. Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.Signature Verification*This authorization is made voluntarily based on my specific understanding that (1) I am not required to sign this form or make voluntary COPE contributions as a condition of my employment by my employer or membership in the union; (2) I may refuse to contribute without any reprisal; (3) I am a U.S. citizen or lawful Permanent Resident of the U.S. and a union member or executive/administrative staff member; (4) The amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from the union or my employer; (5) SEIU COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU Healthcare 1199NW.Authorization* I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Committee on Political Education (SEIU COPE). Union Membership* I attest that I am a member of SEIU Healthcare 1199NW Signature Verification*
