Membership form

Florida Education Association
213 South Adams Street
Tallahassee, FL 32301 (1-888-807-8007)
2655 Capital Circle N.E. Suite #7
Tallahassee, FL 32308 (1.888-812-2920)
SCHOOL OR WORK SITE
LOCAL ASSOCIATION
SOCIAL SECURITY NUMBER
REG
SERVICE CNTY
LOCAL
DIST
UNIT
LASTNAME
FIRST NAME
M.I
NAME
Association
ADDRESS
Membership
Annual
Code
Payment
National
CITY &
State
ZW
STATE
rIOME
PFIONE
WORK
PHONE
()
Service
E-MAIL
()
l.lnit
Local
INITIAL YEAR
TOTAL
SEE CODES ON BACK OF FORM
SUBJECT
CODE
SEX
CODE
DATE OF
BrRrH I
Pa)'roll Deduction.
I
REG.VOTER
CODE
PARTY AFFIL.
CODE
PRECINCT
NO
I
hereby agree to pay, and, authorize my employer to deduct, the dues and
assessments described above and as are certified by the Association to tfre School
board for each year
thereafter from my salary and direct and authorize my employer to pay such amounts to
the
Association in accordance with payroll deduction procedures -in effect; provided, however,
I may
cancel my membership and this authorizalion by providing 30 days'written notice to
the School
Board and Association notifying them of such revocation as providej by law.
Cash Member. I hereby agree to pay to the association the dues and assessments
described above and
as may be prescribed by the Association and certified to the School Board
for each year thereafter.
I\4EMBER,S SIGNATURE
DATE
LOCAL
AS
SOCIATION REPRESENTATIVE
tt'hich
i.s
applicohle to:1's,,.
Subject
0l Adult Bnsir EdLtcatiou
02 Agriculture
03 Architecturc
04 Arca Studies
0-i Art
06 Biological Science
07 Bu:iiness
08 Cornmunications
09 ConryLrler Science
I0 DrivelEducation
1l Education
12 Errgineering
13 English/Language Arts
14 Fine anclApplied Arts
15 Foreign Lang. & Lit.
16 Forestry
17 Geography '
Itl Health & Phys. Educ.
19 Health Professions
20 HorneEconornics
2l Industrial Art
22 Interdisciplinary Studies
23 Lav,
24 Library Science
2-5 Mathematics
26 Military Scjence
27 Mlsic
28 Philosophy
2-9 Physicai Science
30
3l
Psychology
Public Services
Positiou
Lerel
0l Autlio-VisunlTechnician 0i Prc.schoul / Kindelgarten
02 Cafetcria Worker
02 Elctnentary
03 Classroonr 'ltacher
0-] lntenrred. i iv'liddle / Junior
01 }tigh
04 Cloach
05 (lounsclor 1 Psvcholo.gist
05 Post-Sec. Voc. Educ.
06 Cuslodian
06 Conrn:unity /.Junior College
07 Flealrh Care Professional
07 College
08 University
08 Librarian
09 Central Site
09 lt4aintenance Personno'l
10 OlficeSupport/Secy.
99 Other
1l Principal /Asst. Principal
Ethnic*
12 Retired
13 Speech / llear. Theripist,
I American Indiat / Alaska
Clinician
Native
2 Asian I Pacifrc Islander
i4 Supervi.sot'/ Director
15 Stafl'Association
3 Black
16 Student
4 Hispanic
17 Superintendent
5 Cjaucasian
(not of Spanish Oligin)
18 Teacher Aide
19 Transpottalion Pers.
9 Unkuorvu
20 Artjunct Faculty
21 Adrnin. OfllcePersonnel
22 Assistant Proi'essor
23 Associate Professor
24 lrrstructor
25 Lecturer
26 Proti:ssor'
Worker
Other
B0 Social
99
I
2
3
National IUembership
[pes
- protbssional
Substitute
25 Active - edricational support
30 Active Life
l0
Active
R
D
I
O
Republican
Democrat
Independent
Other
Method of Payment
Curic.
32 Reading
33 Religion and Theology
34 Science
35 Social Sciences
36 Social Studies
37 Specinl Education
38 Speech & Drama
39 Vocational Education
90 No Subject Tarrght
91 Gerreral Subjects
99 Other
Part.l'Afliliation
15
33 Active Life i Retirecl Lifle
35 Active Life'/ Retired Arurual
40 Staff
45 Reserve
50 Retired-Annual .
53 Retlred-Litbtime
59 Pre-Retired - Lifetirne
60 Student
Cash
Payroll Decluction
Easy Pay
Rtgistered Voter
Y
N
U
Yes
No
Unknowu
Sfate lHernbership
t0
Active
['pe
15 Substitute
25 Educational Support
.30 Lit-e)r*x
40 Staff
45 Reserve
50 Retired - Annual
-53 Retired - Lifetime
59 Pre-Retired - Lifetime
60
*Eth-nic minority information is optional and failure to provicle il
lvill iu no
Studenr
rvay af fect your niembetsltip statrrs, rights, or
berrefits. This infornation u'ill be kept confideltial.
*sxAyailable only to those Life nrernbers ofihe Fiorida Erlucation Association (FEA)
F.EA urembership and requested its tmnsfer prior to Septernber l, 1982.
as
ofApril,
1975 u,l:o resigr:eci their