Local No.4 Check-Off Authorization

Mobile Enrollment Form

First Name *

Last Name *

Street Address *

City *

State * 2-letter abbreviation (NY, NJ, CT, etc.)

Zip Code * 5 digits only (example: 11201)

Cell Phone *

Email *

Social Security Number * Format: 123-45-6789

Primary Employer

Date *

Additional Authorizations

I authorize Local No.4 to contact me via email and text for work calls, updates, and union business. I authorize the Union to maintain my information for internal records and dispatch purposes.

4.0% Wage Assignment Disclosure *

I ACCEPT the authorization for a 4.0% wage assignment as described in the disclosure below.

You must read and accept this disclosure before submitting the form.

By tapping "Submit Authorization" you confirm that all information provided is accurate to the best of your knowledge.

Mandatory Disclosure

Effective immediately, the undersigned assigns to Theatrical Stage Employees, Local No. 4, IATSE, four percent (4.0%) of all wages earned and to be earned by him as an employee and authorizes and directs his employer to deduct such percentage from his wages and to remit same to the Union. This assignment shall be irrevocable for a period consisting of either one (1) year or until termination of this agreement whichever is sooner, and shall be automatically renewed, with the same irrevocability for successive like periods, unless terminated by the undersigned in writing not more than twenty(20) nor less than ten(10) days prior to the expiration of such periods. Furthermore, the undersigned authorizes and directs his employer to provide Local No.4, IATSE with any/all employee information they may request.