MEMBERSHIP FORM
Name
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First Name
Middle Initial
Last Name
Last four digits SSN:
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School or Worksite:
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Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cellular Phone Number
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-
Area Code
Phone Number
Home Email Address:
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example@example.com
Select Payment Method:
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Payroll Deduction: I hereby agree to pay and authorize my employer to deduct the dues certified by the Association to the School Board for each year thereafter from my salary and direct and authorize my employer to pay such amounts to the Association in accordance with payroll deduction procedures in effect; provided, however, I may cancel my membership and this authorization by providing 30 days written notice to the School Board and the Association notifying them of such revocation as provided by law. Furthermore, if I receive a membership incentive (dues rebate or a “free months” promotion), I will not cancel membership during the first twelve (12) months without reimbursing the Association for said incentives.
Cash Member: I hereby agree to pay to the Association the adopted dues and assessments in full and as prescribed by the Association and certified to the School Board for each year thereafter.
MEMBER'S SIGNATURE
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