Certified Religious Accommodation Request
Supporting Law: Title VII of the Civil Rights Act of 1964, 42 U.S.C. Section 2000e et. seq.
Labor Union Involved: ___________________________________________________
Equal Employment Opportunity Commission Guidelines on Discrimination,
Part 1605.2 (d)(2):
“Payment of Dues to a Labor Organization.”
“Some collective bargaining agreements include a provision that each employee
must join the labor organization or pay the labor organization a sum equivalent
of dues. When an employee’s religious practices do not permit compliance with
such a provision, the labor organization should accommodate the employee by
not requiring the employee to join the organization and by permitting him or her
to donate a sum equivalent to dues to a charitable organization.”
I am employed by: ______________________________________________________
Employer’s address: _____________________________________________________
Hire Date: ____ /____ /____
____ Presently I AM paying union dues: ____ Presently I am NOT paying union dues:
Based on both the “historically held” teachings of my church and my own personal religious
conviction, I request that I not be listed as a member of the union and that I not be required to pay
dues to the union.
As is provided for in the above laws, “to pay sums equal to such dues and initiation fees to a
non-religious, non-labor organization charitable fund”, the following charity is my personal choice:
I respectfully request that my employer hold the funds to be contributed to the charity in escrow
until we have agreement on the choice of charity and the accommodation request has been processed.
Employee’s Signature: _________________________________ Date: ____________
Employee’s Address: _____________________________________________________
Signature of Church Official: ____________________________________________
Title of Official: ________________________________________________________
Address of Church Official: ________________________________________________
“I do hereby verify that___________________________________________ is a member
of the __________________________________________Seventh-day Adventist
Attached please find the official position statement from the Seventh-day Adventist Church.