WVPE Membership Form

West Virginia Professional Educators, Inc. Membership Application
Name *

First Name Last Name
E-mail *
Phone Number: *

Area Code Phone Number

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

County Where Employed
County of Residence *
School Position
Referred by:
Type of Membership

Full Time Membership Partial Year 2018-2019 ($75) Full Time Membership, 2019-2020 School Year ($150) Substitute Teacher ($75) Long Term Substitute($150) Student w/ Insurance ($25) Student w/out Insurance ($5) Retired Personnel ($20) Legislator ($20) Friends of Education ($20)

Future Membership: Choose one of the following options to continue membership beginning next school year

Continuous Membership. I hereby authorize my employer to deduct the dues from my salary in installments. It is expressly understood that deductions from my salary will continue unless cancelled by written request or by termination of employment. I plan to renew my membership annually and pay each time.

Signature *

Clear
DateTime
Should be Empty: