WSSRA MEMBERSHIP FORM
Annually $84.00 will be charged to your Credit/Debit Card.
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Cell Phone Number
Personal Email
*
Confirmation Email
example@example.com
SS Number
Please select your Unit.
Unit 01 Asotin/Pomeroy
Unit 02 Chelan-Douglas
Unit 03 Clallam County
Unit 04 Columbia Basin
Unit 05 Grays Harbor/Pacific
Unit 06 Southwest King
Unit 07 Jefferson County
Unit 08 Kitsap County
Unit 09 Kittitas County
Unit 10 Columbia Gorge
Unit 11 Lewis County
Unit 12 Lower Columbia
Unit 14 Mason County
Unit 15 Okanogan County
Unit 16 East King
Unit 18 Pend Oreille County
Unit 19 Renton-South King
Unit 20 Seattle
Unit 21 Skagit/Island/SJ
Unit 22 Sno-Isle
Unit 23 Sno-King
Unit 25 Spokane Area
Unit 27 Pierce County
Unit 28 Thurston County
Unit 29 Benton-Franklin
Unit 30 SW Washington
Unit 31 Walla Walla-Col
Unit 32 Whatcom County
Unit 33 Whitman County
Unit 34 Yakima County
What Unit do you want to belong to?
Retirement Date
(Month and Year)
Retirement Plans
Select One
TRS 1
TRS 2
TRS 3
PERS 1
PERS 2
PERS 3
SERS 2
SERS 3
School District (where last employed)
What School District where you where last employed?
How did you hear about us?
Letter from Washington State School Retirees
AMBA Benefit mailing
AMBA Representative call or meeting.
Friend or co-worker
Facebook advertisement
Other
Agent:
Please let us know the Agent or AMBA Representative that assisted you?
Dues:
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next
( X )
WSSRA
(
$
84.00
for each
year
)
Membership Dues
Email
Credit/Debit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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