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Please enter your employee identification number, usually located on your pay stub.

I hereby authorize and direct my employer to deduct $15.00 per month from my paycheck and pay the same to the Utah Public Employees’ Association (UPEA) as dues for membership in that organization and agree that said payroll deductions shall continue until I revoke this authorization by giving written notice to UPEA.  Authorization for withholding UPEA dues will remain in effect even after retirement unless a member gives written notice to UPEA.  Upon retirement this form authorizes the Utah Retirement Systems to deduct $5.00 per month from my retirement allowance.  This payroll deduction authorization shall serve as my application for membership in UPEA and shall designate UPEA as my employee representative for all purposes provided by the law.

By typing your name in the box below, you agree to the above terms.

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