I hereby assign to the Brotherhood of Maintenance of Way Employes Division (BMWED) that part of my wages necessary to pay my monthly union dues (not including fines and penalties) as reported to the BNSF Railway by the appropriate General Chairperson of the BMWED System Division or System Federation to which I am assigned. Such reports will be made in the form agreed upon between the parties and as provided in the Dues Deduction Agreement entered into between BNSF Railway and its employees represented by the BMWED effective January 1, 1980.

I hereby authorize BNSF Railway to deduct from my wages all such sums and remit them to the BMWED National Division Secretary Treasurer in accordance with the said Dues Deduction Agreement.

This authorization may be revoked by the undersigned at any time after the expiration of one year from the date of its execution, or upon the termination of said Dues Deduction Agreement, or upon the termination of the Rules and Working Conditions Agreement between BNSF Railway and BMWED, whichever occurs sooner.

Dues contributions or gifts to the BMWED are not deductible as charitable contributions for federal income tax purposes. Dues paid to the BMWED, however, may qualify as business expenses and may be deductible in limited circumstances, subject to various restrictions imposed by the Internal Revenue Code.

I, the undersigned:

Apply for membership in the Brotherhood of Maintenance of Way Employes Division—IBT, and agree to abide by its Constitution and Bylaws;
Authorize this Union to be my exclusive bargaining agent.

First Name:
Middle Initial:
Last Name:
Phone Number
Cell Provider:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Email Address:
Social Security Number:	- -
Birth Date:
Preferred Greeting:	Brother Sister
Employee ID Number:
Service Entry Date:
District:
Hire Location:
Occupation:
Are you a Veteran?
If yes, what branch?
EMERGENCY CONTACTS
1. Emergency Contact Name
Emergency Contact Phone
Relationship
If Other, please describe

2. Emergency Contact Name
Emergency Contact Phone
Relationship
If Other, please describe

3. Emergency Contact Name
Emergency Contact Phone
Relationship
If Other, please describe

Todays Date:
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