First name required Last name required Mailing Address (please include full address, city, state, and ZIP) required
School/Worksite required Employee ID Cell Phone required Personal Email required Bargaining Unit required—Please choose an option—SRPInstructional Recruiter (Person you spoke with about joining)
I authorize United School Employees of Pasco (USEP) to initiate the scheduled membership payment each payroll period to coincide with the District School Board of Pasco County’s (DSBPC) payroll dates in the amount as annually certified by said Organization. If the payment date falls on a date that the bank does not process payments, the payment will be deducted on the next day that the bank does process payment. I agree to maintain sufficient funds in my deposit account to permit the automatic transfer described above.
Account Holder Name (If different from above name) Financial Institution Name required Bank Routing Number required Checking Account Number required Note / Special Instructions (optional)
This authorization shall remain in full force and effect for all purposes while I am employed by the DSBPC or until revoked by me upon thirty (30) days advance written notice to USEP.
Employee Digital Signature required Date required
