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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: ___________________________________________________

Employee: ___________________________________________________________

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:

Charity: _____________________________________________________________

Address: ____________________________________________________________

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.