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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).  

    1. Your Personal / Contact Information
    2. Information Your Work Location, Position / Role
    3. Your Banking & Payment Information For Membership Dues
    4. Your Signatures of Commitment & Payment Authorization
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    Please tell us your first and last name.
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    Your response to this question is OPTIONAL.
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    Your response to this question is OPTIONAL.
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  • 7
    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
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    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.
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    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.
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    Your response to this question is OPTIONAL.
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    This information is optional and will be kept confidential.
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    -
    Pick a Date
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    This is optional and will be kept confidential.
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    For example: NEA-Topeka or leave blank if you are unsure.
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    Student members are a category of membership for college / university pre-service educators.
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    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.
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  • 19
    What building or facility are you primarily assigned to? For example: 'Jones High School', 'Truman Elementary School', 'district office' or 'facility services'.
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    Your response to this question is OPTIONAL.
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    Your response to this question is OPTIONAL.
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    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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    For example: art, music, history, math, etc.
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    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.
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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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    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."
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    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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