TelecomPioneers
Maryland Chapter 44

Application For Membership

Date:___________

Name_______________________________________________________________

Spouse Or Significant Other's Name____________________________________

Home Address_______________________________________________________

City__________________________ State__________ Zip_________________

Home Tel # ( ) - __ __ __ - __ __ __ __ Bus. Tel # ( ) - __ __ __ - __ __ __ __

Work Address_______________________________________________________

Work Department & Title______________________________________________

Fax # (___ ) - __ __ __ - __ __ __ __ On Lotus Notes ? Yes _____ No _____

Email Address:________________________________________

Service Date_________________ Birth Date: Mo.____ Day____ Year____

Social Security Number - __ __ __ - __ __ - __ __ __ __

Note: Annual dues are $15.00 which are collected monthly in $1.25 increments by
payroll deduction the first pay period of the month.

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Verizon Corporation
Payroll Deduction Authorization for Pioneer Dues

/___ /__ /__ / -- /__ /__ / -- /__ / __/ __/__ /
Social Security Number

_______________________ ________________ ___
Employee Last Name -- First Name -- Initial

Check One: ___ Establish new allotment of $1.25 per month ____Cancel existing allotment

Chapter Name: Maryland Chapter
Chapter Number: /_4_/_4_/
Home Zip Code: /__/__/__/__/__/

I hereby authorize and direct the Verizon Corporation to take the action indicated as soon as practicable. In the case of an Allotment Authorization, the above stated allotment is for membership in the Verizon Telephone Pioneers of America. I further authorize the monthly allotment to be taken in the first pay period of each month and on my behalf to transmit the amounts so allotted to the Telephone Pioneers of America. If there is an insufficient amount of wages and benefits due me for the pay period in which the allotment is scheduled, to permit such allotment, I authorize the Company to take the allotment authorization in the next pay period in which there is a sufficient amount.
Any previous Pioneer Dues allotment authorization heretofore given by me to the Company is hereby revoked and this authorization to allot Pioneer Dues shall continue in effect until revoked by me in writing. The Company may, as it's election at any time, cease making allotments hereunder upon giving written notice to me to that effect.
In the case of cancellation of the existing allotments, I hereby cancel the authority previously given to the Verizon Corporation to make allotments from my wages and benefits for transmission to the Telephone Pioneers of America.

___________________________________________________ _________________
Signature of Employee -- Date

Verizon Employees return application and payroll deduction card to:

Maryland Chapter #44
99 Shawan Road
Room G-8
Cockeysville, MD 21030

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Print this page or click here to download the Membership Application MS Word copy and click here to download the Dues Card MS Word copy.