IRTA Membership - Dues Deduction Online Form

IRTA DUES DEDUCTION
MEMBERSHIP FORM

828 S. 2ND ST | 4TH FLOOR | SPRINGFIELD, IL 62704
217-523-8488
irta@irtaonline.org | www.irtaonline.org

First Name*

Middle Name

Last Name*

Street Address*

Street Address Line 2

City*

State / Province*

Zip / Postal Code*

Phone Number*

Area CodePhone Number

Personal Email (No District Emails Please)*

example@example.com

Date of Birth*

Date

Retirement Year*

Which School District did you retire from?*

Dues Deduction Authorization*

I hereby authorize the Teachers Retirement System to deduct my IRTA dues in monthly installments at an initial rate of $3.50 or as subsequently established by the Delegate Assembly.

Signature Required for Dues Deduction - (Hold Your Mouse Button While Signing)*

TRS Requires the last four digits of your Social Security Number for Identification. *

Please verify that you are human*