LOCAL NAME & BILLABLE PARTY ID
Our Association provides resources and support to
educators to ensure student success. How can we
help you in your career and practice as an educator?
❑
Student Behavior/Classroom Management
❑
Curriculum Assistance
❑
Access to Mentors and/or Coaches
❑
Working with Parents
❑
Working with Administrators
❑
Understanding your Evaluation/Observation
Process
Our Association works to ensure every school
provides our students with the opportunities to
succeed. Which of the following issues are most
important to you?
❑
Social and Racial Justice
❑
Economic Justice
❑
Parental and Community Engagement
❑
Fully-Funded Schools
❑
Conditions in the Workplace
❑
Education Policy
❑
Political Advocacy
Our Association advocates for conditions that retain
high-quality educators for students. Which of these
are you interested in learning about?
❑
Compensation and Contracts
❑
Educator Rights and Responsibilities
❑
Health Care and Insurance
❑
Pension and Retirement Benefits
❑
Student Debt and/or Finances
❑
Stretching Your Paycheck
Member Signature Date
Association Representative Signature Date
//
//
By providing my phone number, I understand that the Illinois Education Association-NEA (IEA-NEA), National
Education Association (NEA) and their affiliates, including the local association, may use automated calling
techniques and/or text message me on my cellular phone on a periodic basis. I understand I can unsubscribe from
receiving such messages by contacting IEAConnect at 1-844-432-1800. The IEA-NEA, NEA and my local association
will never charge for text message alerts. Carrier message and data rates may apply to such alerts.
I agree to my unified membership in the IEA-NEA, NEA and my local association (including any other association
which is my exclusive bargaining representative and affiliated with the IEA-NEA)(“Association”) and that my
membership shall be continuous unless I provide written notice signed by me stating that I no longer want to be
a member. Such notice shall also include the name of my local association and be sent via U.S. mail to either the
IEA President or my local association president at the following address: 100 East Edwards St., Springfield, Illinois
62704.
I agree to submit dues to the Association and hereby authorize my employer (including any other employer to
which my employment is transferred by law or agreement) to deduct from my pay such dues and voluntary
contributions to IPACE, as these sums are annually established, and to NEA FCPE , and to forward such amounts
to my local association (or IEA-NEA, if the local association is no longer affiliated with IEA-NEA). This authorization
is to continue in force, regardless of my membership status, unless a) revoked by me for a succeeding membership
year by giving written notice to that effect to both my employer and local association on or before September 15
or b) my employment ends.
Dues payments and contributions or gifts to IPACE and NEA FCPE are not deductible as charitable contributions
for federal income tax purposes. Dues payments may be deductible as a miscellaneous itemized deduction.
The invalidity or unenforceability of any particular provision shall not affect the validity and enforceability of other
provisions in this Agreement.
❑
AC-1-100 Active Professional FT
❑
AC-1-75 Active Professional (¾)
❑
AC-1-50 Active Professional PT
❑
AC-1-25 Active Professional QT
❑
AC-2-100 Active ESP FT
❑
AC-2-75 Active ESP (¾)
❑
AC-2-50 Active ESP PT
❑
AC-2-25 Active ESP QT
.
.
.
.
.
NEA Dues
IEA-NEA Dues (1)
NEA FCPE (2)
Local Dues
TOTAL
Membership Category
Payment Method
Association
Dues/Contributions
PLEASE PRINT USING UPPER CASE ONLY — USE BLACK OR BLUE INK ONLY
0 0
❑ ❑ ❑
Last 4 digits of your
Social Security Number
First name
Middle name
Last name
Former name
Home address
City
State Zip
Cell
Personal
Work
Home Work
Ethnicity (Optional)
Gender identification
Date of birth
Preferred phone
Personal email
Work email
(enter ø for zero)
Preferred email
(check one)
Employer
Worksite
(work location name)
Employment start date
(in this local)
Position
Please identify your first year employed in education
Subject
Phone type
(check one)
Membership Number
(refer to your IEA membership card)
/
--
/
//
❑
American Indian/Alaska Native,
❑
Black,
❑
Hispanic,
❑
Caucasian (not of Spanish Origin),
❑
Asian,
❑
Native Hawaiian/Pacific Islander,
❑
Multi-Ethnic,
❑
Other,
❑
Unknown (UK)
❑
❑
❑❑
(advocate for policies that ensure all students
get the opportunities they deserve)
(policy that impacts your school at the local,
state or national level)
Payroll Deduction
Check
❑
❑
(see back)
(see back)
xxx-xx
