AUTHORIZATION AGREEMENT
FOR CREDIT CARD DEDUCTIONS
CWA RETIRED MEMBERS’ COUNCIL COPE	

I hereby authorize the Communications Workers of America Committee on Political Education Political Contributions Committee, hereinafter called the CWA-COPE PCC to initiate a deduction from my credit card.

This authorization is to remain in full force and effect until the CWA-COPE PCC has received written notification from me of its termination in such time and in such manner as to afford the parties a reasonable opportunity to act on it.

Check one:	  New Enrollment	       Change of Amount	   Cancel Deduction

I authorize a contribution of (choose one):    $8.00 per month    $10 per month

My choice of incentive award is indicated on the reverse side of this form.

 VISA                    MasterCard

Card # ___-___-___-___  ___-___-___-___  ___-___-___-___  ___-___-___-___

Expiration Date (MM/YY):  ____/____   	 Card Security Code:  ______ *
*The Card Security Code ("CSC" for short) is a three- or four-digit number printed on the credit card for security purposes.  On most cards, the CSC is three digits long and is printed on the back of the card (usually in the signature field). Other numbers may appear to the left of the CSC.

________________________________________________            	____________________
(Retiree Signature)						    		(Date)

______________________________________            ________________________________________
(Print Name)								(E-mail Address)

____________________________________________________________________________________
(Mailing Address)				(City)				(State / ZIP)

___________________________________				Chapter Number ___________
(Phone Number)

RETIRED	     			RETIRED			   ____-____-____-____
(Name of Employer)			(Occupation)		        	   (Last 4 Digits of Social 
                    Security Number)
This Authorization is voluntarily made based on my specific understanding that:
•	The signing of this authorization card and the making of contributions to CWA-COPE PCC are not conditions of membership in the union and that I may refuse to do so without fear of reprisal.
•	I am making a contribution to a joint fund-raising effort sponsored by CWA-COPE PCC and the AFL-CIO Committee on Political Education Political Contributions Committee (AFL-CIO COPE PCC) and that CWA-COPE PCC and AFL-CIO COPE PCC will use my contributions for political purposes, including but not limited to, the making of contributions to or expenditures on behalf of candidates for federal, state and local offices and addressing political issues of public importance.
•	Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and the name of employer of individuals whose contributions exceed $200 in a calendar year.
•	Contributions or gifts to CWA-COPE PCC and AFL-CIO COPE PCC are not deductible as charitable contributions for federal income tax purposes.	

RETURN TO:	CWA RMC
501 THIRD STREET, NW
WASHINGTON, DC 20001-2797		

RMC COPE 
INCENTIVE AWARD PROGRAM

Please indicate your level of giving and your choice of award incentive:

_____	Triple Quorum - $8 per month
		____ Duffle Bag or
		____ 26 Quart Cooler

_____	President’s Club - $10 per month
		____ CWA Watch or
		____ Day Calendar or
		____ 5” Knife