Fill out this form to authorize EMPAC deduction from your payroll or pension.

[form]

North Carolina law requires political committees to report the name, mailing address, job title or profession and name of the employer or the employer’s specific field for individuals contributing in excess of $50 in an election. Contributions are limited to $4,000 per individual per election and must be made from personal funds. PAC contributions are not tax deductible.

By submitting this form you hereby authorize your employer to deduct voluntary contributions, in the amount designated above, from my wages/pension on a monthly basis, for transmittal to SEANC in a lump sum with my SEANC dues. These authorizations shall continue until canceled by me by written notice to SEANC.