PEA Membership Form

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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 *

YYYY

Ethnicity (optional)

Gender (optional)

US Citizen (see #4 on Membership Agreement) *

Yes

Required

Registered Voter (optional)

Yes

Political Affiliation (optional)

School/Worksite *

Membership Type *

Full-time

Part-time/Contract

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)

First-Year Teacher

Payment Method *

Dues Agreement *

I have reviewed this form in its entirety and hereby authorize the continuing payment or dues deduction of unified duees (PEA, CEA, NEA) unless I revoke this authorization in writing to my local association in accordance with PEA's Bylaws. I also authorize modifications of the associations' dues (see #1 on Membership Agreement)

Required

Association Representative Name (list N/A if unknown) *

Member Signature *

Submit

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