I hereby authorize the sum of $ *

Account Number

Routing Number

Name

Address

This authorization is voluntarily made on my specific understanding that: • The signing of the authorization card and the making of these voluntary contributions are not conditions of membership in the Union or of employment by my employer; • That I may refuse to contribute without reprisal; • And that OKFIREPAC may use the contributions they receive for political purposes, including but not limited to making contributions to candidates, conducting expenditures on behalf of candidates, and addressing political issues of public importance. I declare that this contribution is given freely and voluntarily from my personal property and I have not been directly or indirectly compensated or reimbursed for this contribution.

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Date