* Includes $14 per month membership for active state employees (or $10 per month for retirees) and $3 per month voluntary Employees Political Action Committee (EMPAC) contribution.

The EMPAC contribution may be declined now by checking this box or may be cancelled at any time with one month's written notice to the SEANC Central Office. If you desire to contribute a different amount to EMPAC, please indicate your EMPAC contribution here:

North Carolina law requires EMPAC to report the name, address, occupation and employer of individuals whose contributions exceed $50 in a calendar year; contributions are limited to $4,000 per individual per election cycle.

I authorize (a) my employer to deduct SEANC membership dues from my wages/pension on a monthly basis, or (b) SEANC to draft membership dues directly from my checking account, in such amounts as are currently established pursuant to the SEANC Bylaws, or in such adjusted amounts as may be approved by the membership subsequent to the date of this authorization. I further hereby authorize my employer or SEANC to deduct voluntary EMPAC contributions in the amount designated above from my wages/pension or checking account 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 the SEANC Central Office. The payments so deducted are non-refundable. SEANC membership dues and contributions to EMPAC are not deductible as charitable contributions for federal or North Carolina income tax purposes.

I understand that: 1) I am not required to sign this form or make contributions to EMPAC as a condition of my employment by my employer or membership in SEANC; 2) I may refuse to contribute without any reprisal; 3) only members and executive/administrative staff who are U. S. citizens or lawful permanent residents are eligible to contribute; 4) the amounts on this form are merely a suggestion, and I may contribute more or less by this or some other means without fear of favor or disadvantage from SEANC or my employer; 5) SEANC and SEIU use the money they receive for political purposes, including, but not limited to, addressing issues of political or public importance and contributing to and spending money in connection with federal, state and local elections.”