The Women's Alliance Membership Application (US Employees Only)

Eligibility All salaried exempt / non-exempt employees of Xerox and its wholly owned subsidiaries.
Dues $5.00 US, per month, non-refundable. Initial dues are payable by monthly payroll deduction ($5 per month) for direct Xerox employees. Payment by check is accepted for ACS, GIS and other subsidiaries.

Please fill in the fields below, even for a renewal.
First Name*
  		Last Name*
  		Age group*
8*
Referring Member Name
  		 Intelnet No.
  		ORG (I.E., USSG, PSG)*
  		Phone No.*  
 
Current Job Title*
  		Internet Email Address*
  		Office City Location*
PAYROLL DEDUCTION:

Applicable to direct Xerox employees only. Please complete the following fields:

Employee #*
Pay Method* Xerox Employee   
  XFCU Employee  


I authorize Xerox Payroll to deduct $5.00 from my paycheck each month for The Women's Alliance. The deduction will show as code M06. The deduction will occur the first pay period of the month for all paycheck frequencies. The deduction will begin the month after TWA Membership (Renée Bates) receives this form and will continue until I authorize The Women's Alliance to stop my deduction.