By contributing, I am aware that (i) contributions to the PAC will be used in connection with elections and are subject to the prohibitions and limitations of the Federal Election Campaign Act; (ii) I have the right to refuse to contribute without reprisal; (iii) the guidelines for contributing are merely suggestions and that I may contribute more or less than the guidelines suggest or nothing at all and will not be favored or disadvantaged by reason of my contribution or my decisions not to contribute; and (iv) I must be a U.S. Citizen or Permanent Resident Alien (i.e., Green Card holder residing in the U.S.) to make a contribution.

Federal law requires the PAC to use best efforts to collect and report the name, mailing address, occupation and name of employer for each individual whose contributions exceed $200 in a calendar year.

I, , hereby voluntarily authorize Republic Services to deduct from my payroll check each pay period to be remitted in my name to Republic Services Employees for Better Government PAC until such authorization is changed by me in writing. The payroll deductions for my contributions to the political action committee should begin on the pay period following submission of this form.

Contributions to Republic Services Employees for Better Government PAC are not deductible for federal income tax purposes.

*PAC membership will be valid for one year from the date of enrollment for individuals who pay by check.