PEA Membership Form
*This information is confidential and will not be sold or used outside of PEA/CEA/NEA
First Name *
MI *
Last Name *
Mailing Address *
City *
State *
Zip Code *
Cell Phone *
Home Email *
PSD Email *
PSD ID Number *
Last 4 of Social Security # (This information is confidential, and will not be sold or used outside of CEA/NEA/PEA) *
Date of Birth *
MM
/
DD
/
YYYY
School/Worksite *
Ethnicity (optional)
Gender (optional)
US Citizen (see #4 on Membership Agreement) *
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Required
Registered Voter (optional)
Political Affiliation (optional)
Membership Type *
Required
If Part-time/Contract, please list percentage:
Position Classification *
If Other, please list classification
Position *
Subject Area if applicable
CEA First-Year Reduced Dues (check box if this is the first year you have ever been employed by any public school district in the US)
Payment Method *
Dues Agreement *
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Required
Association Representative Name (list N/A if unknown) *
Member Signature *
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