---

INDEPENDENT SMALL EMPLOYER

MEMBERSHIP AGREEMENT

I do hereby accept and agree to the terms and conditions as set forth under this AMERICAN EMPLOYEES ASSOCIATION Voluntary Employees’ Beneficiary Association (VEBA) General Association Membership agreement and authorize the AMERICAN EMPLOYEES ASSOCIATION to automatically charge/draft my membership contributions by Electronic Funds Transfer (EFT) from my bank or financial institution, credit or debit card, checking and/or savings accounts. This authority is to remain in effect until AMERICAN EMPLOYEES ASSOCIATION receives written notification from me revoking the authorization and membership. My account will be drafted each month on or about the effective date of my membership not to exceed the amount stated and agreed to above. I confirm that I am solely responsible for paying any bank or financial institution fees related to my EFT transactions. I declare under penalty of forfeit of membership and benefits that I am eligible under the governing rules of the organization and the information submitted herein is true and correct.

I hereby acknowledge, understand, accept and agree to the membership fee schedule(s) and to pay the annual contribution, trust, administration as well as all other applicable service fees under the terms and conditions of this membership agreement.

By clicking on the subscribe and payment button above, I acknowledge and confirm I have read, understand and agree to the terms and conditions setforth under this agreement.