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MEMBERSHIP FORM
Monthly Dues Deduction-

Employed (deduction from paycheck)

or

Retired (deduction from pension)
First Name
Middle Name
Last Name
Address

Street Address

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Cell Phone Number
Personal Email
example@example.com
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SS Number
Washington Department of Retirement and School Districts require SSN# for deductions.
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Retirement Plans
Retirement Date
(month and year)
School District (where currently or last employed)
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Payment method

$7 monthly from my paycheck$7 monthly from my pension check
I authorize my school district and upon my retirement, the Washington State Department of Retirement Systems to deduct the following dues and any future increases as voted by the membership from my monthly paycheck, or WSDRS pension check, and to pay such deduction to Washington State School Retirees Association. Dues are not tax deductible.
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