CAPITAL UNISERV Active Professional / ESP Membership Application 2024-2025

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Kansas National Education Association

Application for 2024-25 Active Professional/ESP Membership

715 S.W. 10th Ave., Topeka, KS 66612-1686

785-232-8271

The data transferred during the submission of this form is securely encrypted by Jotform.
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To complete this form, we need to collect information in the following four categories. All information is fully encrypted and secure and will only be used for KNEA, NEA, and local affiliate purposes. We do not sell or share your information with any other party, except as required to provide service to our members (for example, some membership information is passed on to NEA Member Benefits).

Your Personal / Contact Information

Information Your Work Location, Position / Role

Your Banking & Payment Information For Membership Dues

Your Signatures of Commitment & Payment Authorization
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May we have your first and last names please?* This field is required.Please tell us your first and last name.
First Name
Last Name
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May we have your middle name?Your response to this question is OPTIONAL.
Middle Name
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May we have your maiden name?Your response to this question is OPTIONAL.
Maiden Name
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Please provide the last four digits of your Social Security Number.* This field is required.
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What is your home address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What is your cellphone number?* This field is required.We require a cell/personal phone number where we are most likely to reach you. We will only use the number you provide to contact you for official KNEA/NEA purposes which may include a few (typically less than 10 per year) SMS / Text message advocacy alerts of a non-commercial nature. You will have an opportunity to opt-out of future messages.
Area Code
Phone Number
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What is your PERSONAL email address?* This field is required.We will use this email to communicate with you to verify membership and for association business including advocacy updates & alerts of a non-commercial nature. You will have an opportunity to opt-out of future messages.
example@example.com
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What is your WORK email address?Your response to this question is OPTIONAL.
example@example.com
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What is your ethnicity?This information is optional and will be kept confidential.
Asian
Caucasian
Black
Hispanic
Native Hawaiian / Pacific Islander
American Indian / Alaska Native
Multiple Races
Other
Unknown
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What is your date of birth?* This field is required.
Date
Month
Day
Year
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What is your gender?This is optional and will be kept confidential.
Female
Male
Transgender Female
Transgender Male
Gender Expansive / Non-Conforming
Other
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What local association are you joining?For example: NEA-Topeka or leave blank if you are unsure.
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Is this your first year of teaching?* This field is required.
YESNO
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Were you a student member last year?* This field is required.Student members are a category of membership for college / university pre-service educators.
YESNO
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Are you a retired educator who has chosen to return to work?* This field is required.
YESNO
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Your membership type is based upon your employment type, either licensed (active professional) or classified (ESP). In addition, you may either be a full-time employee or a part-time employee. Select your membership type below.* This field is required.Select the ONE membership type that best matches your employment status. If you are unsure click "UNSURE", we can help verify your employment status later.
Full-Time Active Professional (LICENSED)
1/2 Time Active Professional (LICENSED)
1/4 Time Active Professional (LICENSED)
Full-Time ESP (CLASSIFIED)
1/2 Time ESP (CLASSIFIED)
1/4 Time ESP (CLASSIFIED)
Unsure
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What is your work location?What building or facility are you primarily assigned to? For example: 'Jones High School', 'Truman Elementary School', 'district office' or 'facility services'.
What building or facility do you work in?
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In what district or institution are you employed?Your response to this question is OPTIONAL.
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What is your Employee ID number if you know it?Your response to this question is OPTIONAL.
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What is your position?* This field is required.For example: teacher, ESP, SPED, ESL, RSP, principal, etc. Enter "unsure" if you do not know what to enter in this field.
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If you are a teacher, what subject do you teach primarily?For example: art, music, history, math, etc.
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Select your dues payment options.* This field is required.NOTE: You will not be charged until we have verified your membership and you will be provided with a full summary of local, state and national dues prior to your first dues withdrawal.
Payroll Deduction
Electronic Funds Transfer From Personal Bank Account
Check (Requires payment in full to KNEA by payment in full must be remitted directly to KNEA and received within 30 days of submitting this application in order for your membership to remain active)
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Important information about legislative attempts to limit your right to freely choose to join and pay dues to your professional association.

The Kansas Legislature continues to threaten your right to organize and freely choose to join your professional association. One way they are working to impact your rights is by limiting your ability to choose to pay association dues through automatic payroll deduction. Many bills have been introduced to limit your right to choose how to join and contribute dues payments via payroll deduction, but none have been signed into law. If such a law is passed, it is our first priority to maintain the highest level of uninterrupted membership services without impacting our members in any way. For these reasons, we require personal banking information even if you elect to pay dues by payroll deduction. This information is securely encrypted and will not be used without your knowledge.
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What is the full name of the bank you will be transferring from?* This field is required.
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What is the routing number of the checking or savings account you will be using?* This field is required.
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What is the account number of the checking or savings account you will be using?* This field is required.
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Is this a checking or a savings account?* This field is required.
Checking
Savings
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Membership Commitment* This field is required.Your signature on this panel indicates that you agree to the following: "I want to join with my fellow employees and become a member of the Kansas National Education Association, my local association affiliate, and the National Education Association. I hereby request and voluntarily accept membership in these associations and agree to abide by the Constitution and Bylaws of all three associations."
Clear
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Annual Payment Authorization* This field is required.I hereby agree to pay the annual dues, fees, and assessments established by the three associations in consideration for the services the union provides. I understand that those annual amounts are subject to periodic change by the governing bodies of the associations. I authorize on a continuing basis, and regardless of my membership status, the payment of those annual amounts established by the three associations through [payroll deduction or other arrangements] unless I revoke this authorization in a signed writing sent to [state association address] via U.S. mail, between August 1 and August 31 of the membership year immediately preceding the membership year for which the authorization is to be canceled. I UNDERSTAND THAT THIS AGREEMENT IS VOLUNTARY AND IS NOT A CONDITION OF EMPLOYMENT AND THAT I HAVE THE LEGAL RIGHT TO REFUSE TO SIGN THIS AGREEMENT WITHOUT SUFFERING ANY REPRISAL.
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Kansas National Education Association

Application for 2024-25 Active Professional/ESP Membership

Important information about legislative attempts to limit your right to freely choose to join and pay dues to your professional association.