Annual salary as of June 30, 2021 $ _______________
Dues calculation x.0090
ACSA dues amount (maximum $1,525) $ _______________
ACSA PAC* +$78.00
Total ACSA dues $ _______________
❏ *Check here if you do not wish to contribute $78 to ACSA’s Political Action Committee.
First Name M.I.
Last Name
Position/Title
Last Four Digits of Social Security Number
District
School
Address
City State ZIP
Work Phone Extension
Work Email Address
Personal Email Address (Required)
❏
Check here if you do not wish to receive ACSA email at your work email
Address
City State ZIP
Home Phone Cell Phone
❏
Opt-in to receive text messages from ACSA.
Preferred Mailing Address
❏
Home
❏
Work
❏
Check here if you wish to view ACSA publications online only.
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ACSA’s Membership Recruitment Team provides assistance
to region leaders and region membership chairs in developing
goals and identifying non-members in districts within their
service areas. The Membership Recruitment Team also promotes
the value of ACSA membership to all administrators and to
those new and aspiring. They are available for presentations
on member benefits and services and are a tremendous
resource of information. To find out how you can contact
your local Membership Recruitment Team member, please call
the Member Services Department at 800.608.ACSA or email
memberservices@acsa.org.
Please detach and retain for your records.
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2021-2022 dues
payment options
DISTRICT/COUNTY OFFICE PAYS
If choosing this option, send form to district for authorization and
payment. This section must be completed by district or county office.
Please indicate:
❏ ACSA Dues (excluding $78 PAC) ❏ Affiliate Dues
❏ District P.O. or check enclosed
❏ Bill district monthly
Authorizing party (please print)
Phone number
Email Address
( )
your job classification
Free Professional Liability Insurance and
$10,000 Accidental Death Insurance
(Regular members only)
You are also eligible for all
member benefits including:
n
In-depth reporting and features through EdCal and
Leadership Magazine
n
Timely news and practical information from ACSA News online
at www.acsa.org
n
Reduced registration to the Leadership Summit.
n
Life, accident, disability and cancer insurances
n
Auto/homeowners and personal umbrella liability coverage
n
Discount purchasing
2021-2022 REGULAR MEMBERSHIP APPLICATION
CA Association of African American Superintendents/Administrators (CAAASA) ....$500 (Supt.)/$100 (Other Admin)
National Association of Elementary School Principals (NAESP) ...............................$235
National Association of Secondary School Principals (NASSP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$250
CA Assoc. of Asian & Pacific Islander Leaders in Education (CAAPLE) ..........................FREE
Check below to become a member in one of ACSA’s official affiliates.
SELF PAY (select one)
❏ Payroll deduction*
Signature
(required for payroll deduction)
✽ I agree that my dues will be deducted by my payroll office. This
authorization shall be in effect until revoked by written notice from myself
or ACSA. I consent to the adjustment of such deduction to reflect any change
in the dues of which the payroll office may be advised by the organization.
❏ Three equal installments (Enclose first payment. Not offered after September 2021.)
❏ MasterCard/Visa (full payment only) ❏ Check (full payment only)
Card Number Exp. Date
Signature (required for credit card charge) Date
❏
Certificated management and supervisory
❏ Certificated management & teacher
(dues based on admin salary)
❏ Classified management and supervisory
❏ Confidential as recognized under EERA
❏ CDE or CTC (Associate Membership optional)
❏ Professor of Education (Associate Membership optional)
❏ Charter School Administrator
❏ Other
Are you represented by an exclusive
bargaining representative?
❏ Ye s ❏ No
The information requested below will remain confidential and will be used for ACSA purposes only and will not be sold to
vendors or any third parties.
business
home
( )
Subtotal Affiliate Dues $
local
representation
For further details, call the ACSA Member Services
Department at 650.692.4300 or 800.608.ACSA(2272)
Fax 650.437.9189 • Email memberservices@acsa.org
Dues prorated for the number of months remaining in the school year for members joining after July 2021.
Referred By (please print one name only)
Contributions to support ACSA's political activities are not tax deductible. ACSA
retains sole discretion over use of member political contributions. Dues may be
deductible as business expenses. ACSA estimates that the non-deductible portion
of dues allocable to lobbying is 13.3 percent.
You are immediately covered by:
❏ American Indian or Alaska
Native
❏ Chinese
❏ Japanese
❏ Korean
❏ Vietnamese
❏ Asian Indian
❏ Laotian
❏ Cambodian
❏ Other Asian
❏ Hawaiian
❏ Guamanian
❏ Samoan
❏ Other Pacific Islander
❏ Filipino
❏ Hispanic or Latino
❏ African American, not
of Hispanic origin
❏ White, not of Hispanic origin
❏ Decline to State
ethnicity
year of birth
_____________________
❏ Decline to State
gender
❏ Male ❏ Female
❏ Non-Binary ❏ Decline to State
orientation
❏ LGBT+
education level
❏ Master’s Degree ❏ Doctorate
❏ Other
social media
❏ Facebook ❏ Instagram
❏ Twitter handle
__________________________________
SRC: _______________
click to sign
signature
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