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I, the undersigned, hereby apply for membership in and designate SEIU Virginia 512 as my authorized representative on matters relating to work economics. I further designate, SEIU Virginia 512 to represent me in any grievance I may have concerning these matters.

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I hereby authorize my employer, Loudoun County Government, to deduct regular membership dues (currently $10 per pay period, but subject to change per a membership vote and in accordance with the organization's constitution and bylaws) payable to the organization, SEIU Virginia 512. This agreement shall remain in effect until it is amended or rescinded by me in writing to both my employer and my employee organization, SEIU Virginia 512.

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Contributions or gifts to SEIU Virginia 512 are not tax deductible as charitable contributions for Federal income tax purposes. However, they may be tax deductible under other provisions of the Internal Revenue Code.