CALIFORNIA SCHOOL EMPLOYEES ASSOCIATION
CHAPTER #108 ONTARIO-MONTCLAIR
Application for CSEA Membership and Salary Deduction Authorization
Last 4 Digits of SSN
*
Chapter Name
*
Insert: Ontario-Montclair
Chapter Number
*
Insert: 108
E mail
*
example@example.com
Name
*
Legal FIRST Name
Legal LAST Name
Middle Name Initial
DOB Month
*
DOB Day
*
DOB Year
*
Initial
*
Female
Male
Address
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Street Address
Street Address Line 2
City
State
Zip
Home Telephone
Mailing Address (if different)
City
State
Zip
Cell Telephone
*
District/Employer
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Ontario-Montclair School District
Work Site
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School Site or Department
Work Telephone
Monthly Contracted Employee
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9 Month Employee
10 Month Employee
11 Month Employee
12 Month Employee
Other
Classification:
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Maintenance & Operations
Office & Technical
Food Service
Transportation
Paraeducator
Special Services
CSEA's Political Education Fund (Optional)
$3.00
$5.00
$10.00
Other
Not interested in CSEA's Political Education Fund at this time.
Initial Here to Authorize CSEA's Political Education Fund Deduction (Optional)
Date
/
Month
/
Day
Year
Date
Member's Signature
Preview PDF
Submit
Should be Empty: