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Hold Politicians Accountable
SEIU Political Action – Healthcare Leadership Fund
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First Name
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Last Name
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Personal Email
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Hospital/Chapter/Agency
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Department of Social and Health Services/Department of Health
EvergreenHealth
EvergreenHealth Monroe
Harborview Medical Center
Island Hospital
Klickitat Valley Health
Lincoln Hospital
Newport Hospital & Health Services
Olympic Medical Center
PMH Medical Center
UW Medical Center-Northwest
UW Research/Hall Health
Valley Medical Center
State of Residence
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Montana
Any other state or territory
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Today's Date
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Hold Politicians Accountable
Because decisions made by politicians in Olympia and Washington D.C. affect healthcare funding and our jobs, SEIU members get involved to hold politicians accountable on our issues.
Contributions to the SEIU Committee On Political Education (COPE) are used to support elected officials who are committed to improving healthcare.
I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Committee on Political Education (SEIU COPE).
$11.99
Other:
per pay period to be forwarded to SEIU Healthcare 1199NW.
Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.
Other 1
Please enter a number less than or equal to
100
.
per pay period to be forwarded to SEIU Healthcare 1199NW.
Contributions or gifts to SEIU COPE are not tax deductible as charitable contributions.
This authorization is made voluntarily based on my specific understanding that (1) I am not required to sign this form or make voluntary COPE contributions as a condition of my employment by my employer or membership in the union; (2) I may refuse to contribute without any reprisal; (3) I am a U.S. citizen or lawful Permanent Resident of the U.S. and a union member or executive/administrative staff member; (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 the union or my employer; (5) SEIU COPE uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU Healthcare 1199NW. Signature:
By applying my name here, I authorize the above.
This field is hidden when viewing the form
Section Break
Hold Politicians Accountable
Because decisions made by politicians in Helena and Washington D.C. affect healthcare funding and our jobs, SEIU members get involved to hold politicians accountable on our issues. Contributions to the SEIU Healthcare 1199NW Montana PAC are used to support elected officials who are committed to improving healthcare.
Contributions to the SEIU Healthcare 1199NW Montana PAC are used to support elected officials who are committed to improving healthcare.
I hereby authorize my employer to withhold the indicated amount per paycheck to forward to SEIU Healthcare 1199NW as a contribution to SEIU Healthcare 1199NW Montana PAC.
$11.99
Other:
per pay period to be forwarded to SEIU Healthcare 1199NW.
Contributions or gifts to SEIU Healthcare 1199NW Montana PAC are not tax deductible as charitable contributions.
Other 2
Please enter a number less than or equal to
100
.
per pay period to be forwarded to SEIU Healthcare 1199NW.
Contributions or gifts to SEIU Healthcare 1199NW Montana PAC are not tax deductible as charitable contributions.
This authorization is made voluntarily based on my specific understanding that (1) I am not required to sign this form or make voluntary SEIU Healthcare 1199NW Montana PAC contributions as a condition of my employment by my employer or membership in the union; (2) I may refuse to contribute without any reprisal; (3) I am a U.S. citizen or lawful Permanent Resident of the U.S. and a union member or executive/administrative staff member; (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 the union or my employer; (5) SEIU 1199NW Montana PAC uses the money it receives for political purposes, including but not limited to addressing political issues of public importance and contributing to and spending money in connection with federal, state and local elections and addressing political issues of public importance. This authorization shall remain in effect until revoked by me in writing via U.S. mail to SEIU Healthcare 1199NW. Signature:
By applying my name here, I authorize the above.
This field is hidden when viewing the form
Section Break
