BST Payroll Services
PAYROLL DEDUCTION AUTHORIZATION
For Pioneer Dues

Work Address
________________________________________________________________________

Room No.
________________________________________________________________________

Street
________________________________________________________________________

City/State
________________________________________________________________________

Zip Code
________________________________________________________________________

Office Phone Number

                             (         )  ____________________________

Company
____BellSouth Telecommunications (BST)
____BellSouth Corporation (BSC)
____Other (please specify)__________________________________________________

Social Security Number____________________________________________________

Pay Group ____Non-management ____Management

Payroll Deduction: $15.00 Membership Dues

For partial year membership dues, enter applicable dates:

From____/____/____ To____/____/____

Form: PF-2175 (5-98) Retention: 3 months

                                                      GENERAL INFORMATION
Pioneer dues support Chapter community projects. Pioneer dues payroll deductions, however, are not deductible as a charitable contribution for federal tax purposes. Effective with this authorization and continuing until canceled by written notice, annual dues will be deducted annually in July of each year in accordance with Article VII, Section 2, of the Association Constitution of the Telephone Pioneers Of America. If for any reason the annual deduction is not made at the normal time, the deduction will be made in a subsequent pay period.

__________________________________________________________      ____________
Employee’s Signature                                                                                 Date

Date Keyed:________________________________________________Initials:_______