I hereby assign to the Brotherhood of Maintenance of Way Employes Division that part of my wages necessary to pay my monthly union dues, initiation fees and assessments (not including fines and penalties), as provided for in the Dues Deduction Agreement entered into between the LS&I Railroad Company and the Brotherhood of Maintenance of Way Employes Division effective July 24, 1979 and I hereby authorize the LS&I Railroad Company to deduct and withhold from my wages all such sums and remit them to the Secretary-Treasurer of the National Division in accordance with said Dues Deduction Agreement. This authorization may be revoked in writing by the undersigned at any time after the expiration of one year from the date of its execution, or upon the termination of the said Dues Deduction Agreement, or upon the termination of the Rules and Working Conditions Agreement between the LS&I Railroad Company and Brotherhood of Maintenance of Way Employes Division, whichever occurs sooner.

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:
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Phone Number
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Address Line 2:
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Social Security Number:	- -
Birth Date:
Preferred Greeting:	Brother Sister
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Occupation:
Are you a Veteran?
If yes, what branch?
Emergency Contact Name
Emergency Contact Phone
Relationship
Todays Date:
Signature	Signature: Use your mouse, finger, or touch device to write your signature.