Membership Enrollment Form

ARE YOU EMPLOYED HALF TIME OR LESS*

ARE YOU EMPLOYED QUARTER TIME OR LESS*

LAST 4 DIGITS SOC. SEC. NO.*

NAME*

First Middle Last Suffix

FIRST - MIDDLE INITIAL - LAST (JR, SR, ETC)

ADDRESS*

Street Address Address Line 2 City State ZIP Code

NON-WORK E-MAIL ADDRESS*

PRIMARY CONTACT NUMBER*

CELL PHONE NUMBER*

AUTOMATED CALL/TEXT

By checking the box, I understand that the National Education Association and its affiliates including, OEA, the Local Association, NEA Member Benefits, and NEA 360 may use automated calling techniques and/or text message me on my cellular phone on a periodic basis. The NEA, OEA, NEA360, NEA Member Benefits or my Local Association will never charge for text message alerts. Carrier message and data rates may apply to such alerts.

I understand

GENDER*

DATE OF BIRTH*

MM/DD/YYYY

MEMBERSHIP ELIGIBILITY DATE*

MM/DD/YYYY

FIRST YEAR MEMBER?*

POSITION*

PRIMARY SUBJECT TAUGHT*

Master Teacher*

NBCT*

ETHNICITY*

*Ethnic minority information is optional and failure to provide it will in no way affect your membership status, rights or benefits in NEA, OEA or any of their affiliates. This information will be kept confidential.

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. Lobby expenses paid or incurred as part of membership dues cannot be deducted from your income taxes. The amount of the OEA membership dues attributable to lobby expenses and actual deductible dues dollars will be reported annually online and in the February issue of Ohio Schools Magazine for all levels of membership.

LOCAL NAME / USER LOCAL ID*

WORK LOCATION NAME / USER WORK LOCATION ID*

UNIFIED CODE*

Unified Education Profession Dues (Local, UniServ, District, OEA and NEA)

ANNUAL DUES*

AFFILIATED / ASSOCIATED - 1

Do you wish to be a member of another affiliated or associated organization?

AFFILIATED / ASSOCIATED - 2

Do you wish to be a member of another affiliated or associated organization?

AFFILIATED / ASSOCIATED - 3

Do you wish to be a member of another affiliated or associated organization?

AFFILIATED / ASSOCIATED - 4

Do you wish to be a member of another affiliated or associated organization?

TOTAL ANNUAL DUES*

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.

MEMBERSHIP ENROLLMENT (Signature Required) I wish to become a member of the Local Association, Ohio Education Association, District 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 four associations.

UNIFIED MEMBER’S SIGNATURE*

(REQUIRED OF ALL MEMBERS)

Date

DUES DEDUCTION AUTHORIZATION (Signature Required) YES, I hereby authorize by method of payment below the payment of the total annual dues, fees and assessments of the organizations indicated herein 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. If payment is by payroll deduction I also authorize and direct my employer to deduct said amounts from my earnings, consistent with the method of payment authorized (Annual or Continuing) and local policy. By choosing continuing payroll deduction I authorize the continuous deduction of said amounts from year to year hereafter without further authorization by me in the amounts to be certified to my employer from time to time. In the event my employment is voluntarily or involuntarily terminated, or I take an unpaid leave of absence, I agree the unpaid balance of the annual dues obligation not deducted during the year will be due the organizations. The payment of the membership dues obligation is accepted unless I revoke this authorization in a written revocation signed by me and delivered to OEA via U.S. Mail or email at the addresses listed on this form to be received during the period of August 1 and August 31 of the membership year immediately preceding the membership year in which the authorization is to be cancelled. In the event I wish to revoke my authorization outside of the period stated above, I agree to pay the OEA as collection agent for the amount indicated herein by continuing payroll deduction or other arrangement, the remainder of the amounts for the membership year.

METHOD OF PAYMENT*

CHECK NUMBER

SIGNATURE REQUIRED*

Date*

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