Payroll Deduction Enrollment Form
Use this form to enroll or transfer your existing membership dues deduction method. This must be submitted before September 5th in order to allow time for processing. If you were on PRD last year, you do not have to enroll again. If you are not sure if you were on PRD, please contact the office at 1-800-542-8844
Your Full Name
*
First Name
Middle Initial
Last Name
Birthdate
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
*
Please enter a valid phone number.
Personal Email
*
example@example.com
School Email
example@example.com
Last 5 digits of your Social Security Number
*
This is required by your LEA's payroll department.
Membership Type
*
Please Select
Educator $198 ($24.75)
First Year Teacher $90 ($11.25)
Support Staff $90 ($11.25)
Choose which best applies to you.
School District
*
Acknowledgement: By signing below I am asking my school district (listed above) to deduct from my salary the sum of $198 ($24.75)or $90 ($11.25) for PENC annual dues. This authorization will continue to be in effect for each ensuing membership year until the school district and PENC have received written notification of termination of this authorization. If for any reason, except death, my employment is terminated, amounts still owing under this authorization shall be deducted from final pay due. PENC will notify annually the member and the school district of any necessary adjustments in annual dues amount.
*
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