I hereby authorize and direct my Employer to deduct from my wages, Working Dues in the amount shown in the current Collective Bargaining Agreement, as required by the Collective Bargaining Agreement between the International Union of Operating Engineers, Local Union No. 841, and all Associations and/or individual Employers or in the amount as approved by the membership of Local Union 841.

I further authorize and direct that the amount so deducted be reported each month on the forms provided by local 841 for payment of fringe benefits and submitted to the proper collecting agent.

This authorization and assignment shall be irrevocable for a period of not more than one (1) year, or until the termination of the applicable Collective Bargaining Agreement, whichever occurs first. This authorization may be revoked by written notice by Certified Mail to the Employer and the Union during the ten (10) day period prior to the yearly renewal date, or during the ten (10) day period prior to the termination of any applicable bargaining agreement, whichever occurs sooner. In the absence of such revocation, sent and received in accordance with the foregoing requirements, this authorization shall be renewed from year to year thereafter.

This Authorization has been accepted and signed by me on this day: