Membership Form (Test) Name* First Middle Last Maiden (if applicable) SSN* Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhonePersonal Email Work Email* Ethnicity Asian Caucasian Black Hispanic Native Hawaiian/Pacific Islander Multi-Ethnic American Indian/Alaska Native Unknown Other (This information is optional and voluntary and kept confidential.)Date of Birth Month Day Year Gender Male Female Local Association (or USD#) Employer Work Location Position Subject Select Membership Type* Full Time (position count 0.61 or more) Half Time (position count 0.60 or less) NEA/AFT $18.78 KNEA/AFT-KS $32.10 UTW/LABOR FED $8.91 TOTAL $59.79 Mthly NEA/AFT $9.39 KNEA/AFT-KS $16.05 UTW/LABOR FED $4.46 TOTAL $29.90 Mthly Is it your first year of teaching? Yes No Were you a member last year? Yes No If so, where? Were you a student member last year? Yes No If so, how many years? University? Are you currently collecting KPERS? Yes No Choose payment method:* Payroll Deduction EasyPay (ACH/EFT=Checking Account) Dues payments are not deductible as charitable contributions for federal income tax purposes. Dues payments (or a portion) may be deductible as a miscellaneous itemized deduction.IMPORTANT NOTE ABOUT EASYPAY You must complete the EasyPay form after submission of this form before your membership can become active.Terms of AcceptanceMembership in NEA, KNEA and the local assocation is required. If paying by payroll deduction, I hearby authorize the Board of Education to deduct from my salary my professional dues and assessments, as these sums are established or suggested annually to the local NEA-affiliated teachers association as indicated and to forward such amounts to that local association. This authorization is to continue in force unless revoked by me for a succeeding membership year by giving written notice to that effect to my local association      I understand that if my employment is terminated prior to the deduction of the amounts authorized herin, the unpaid portion of dues, assessments will be deducted from my final check.Electronic Signature* I understand that this constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.CAPTCHA Δ
