I hereby assign to the Brotherhood of Maintenance of Way Employees 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 Northern Indiana Commuter Transportation District and the Brotherhood of Maintenance of Way Employees, effective January 01, 1980 and I herb authorize the Northern Indiana Commuter Transportation District to deduct and withhold from my wages all such sums and remit them to the National Division Officer of the Brotherhood in accordance with said Dues Deduction Agreement. This authorization ay be revoked in writing by the undersigned at anytime after on year from the date of its execution, or upon the termination of the said Dues Deduction Agreement, or upon termination of the Rules and Working Conditions Agreement between the Northern Indiana Commuter Transportation District and the Brotherhood of Maintenance of Way Employees, whichever occurs sooner.

In addition, I hereby voluntarily apply for membership in the Brotherhood of Maintenance of Way Employees Division of the International Brotherhood of Teamsters (hereafter the "Union") and I agree to abide by its Constitution and Bylaws. I authorize the Union and its successor or assign to act as my exclusive bargaining representative for purposes of collective bargaining with respect to wages, hours and other terms and conditions fo employment with NICTD. I agree to remain a member in good standing for not less than one year from the date of this authorization.

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:
Hire Location:
Occupation:
Are you a Veteran?
If yes, what branch?
Todays Date:
Signature	Signature: Use your mouse, finger, or touch device to write your signature.