MEMBERSHIP FORM FOR BVEOP

Name:  __________________________________________________

Employee #:  _____________________________________________

Building/Department:  ______________________________________

E-Mail Address:  __________________________________________

I hereby authorize Boulder Valley School District payroll department to deduct BVEOP dues in the amount of $5.00 starting:

______________________________

Signature:  _________________________________   Date:  _____________________

Please remit form to Lynne Daughenbaugh, TEC Print Shop, X5160

Thanks for your support!