I hereby authorize my Employer to deduct from my salary each pay period my PBA dues as certified to the Employer by the PBA. I understand this authorization is voluntary and I may revoke it at any time by giving my Employer and the PBA thirty (30) days advance notice in writing. _______________________________________ Date _______________________________________ Print Name _______________________________________ Job Title _______________________________________ Signature _______________________________________ Social Security Number _______________________________________ Department/Division/Activity/Payroll Number pinellas/AuthDeduct rev.1/99 Print this form, complete it, and mail it to: 14450 46th Street N, # 115 Clearwater, FL. 33762