Step 1: Join! 2020-2021 Enrollment Form: NEA, MSEA and _______________________________________________________
LOCAL ASSOCIATION
NEAs 3 million members are united every day to guarantee a great public education for every student. Join us!
MEMBERSHIP COMMITMENT: YES! I want to join my fellow employees and become a member of the local association,
the Maryland State Education Association (MSEA), 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 three associations.
ANNUAL PAYMENT AUTHORIZATION: YES! I hereby agree to pay the annual (Sep. 1 – Aug. 31) dues, fees, and
assessments established by the three associations 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. I authorize on a continuing
basis, and regardless of my membership status, the payment of those annual amounts established by the three associations
through payroll deduction unless I revoke this authorization in a signed writing sent to your local affiliate via U.S. mail between
August 15 and September 15 of the upcoming membership year for which the authorization is to be cancelled.
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.
______________________________________________________ ________________________________
SIGNATURE (REQUIRED)
(TYPED NAME UNACCEPTABLE. MUST BE PRINTED & SIGNED OR SIGNED IN ADOBE ACROBAT) DATE (REQUIRED)
Dues payments are not deductible as charitable contributions for federal income tax purposes.
______________________________________________________________________________________________________________________________
First Name Middle Initial Last Name
______________________________________________________________________________________________________________________________
Address City State / ZIP
______________________________________________________________________________________________________________________________
Personal Email Work Email Cell Phone*
______________________________________________________________________________________________________________________________
Last 4 digits of Social Security # Employee ID No.
______________________________________________________________________________________________________________________________
Worksite/Building Position/Subject Hire Date
Employment: Employed more than 50% Half-time or less
2020-21 Salary: Over $46,489 $23,245 to $46,489 below $23,245
Payment Type: PAYROLL DEDUCTION CASH/CHECK (requires full payment of annual dues)
Ethnicity: American Indian / Alaska Native Asian Black Hispanic Multiple Races
(Optional)
Native Hawaiian/Pacific Islander White Other
Gender:
Female Male Transgender Female Transgender Male Gender Expansive/Non-Conforming Other
(Optional)
* By providing my phone number, I understand that the National Education Association, NEA Member Benefits, NEA360, the MSEA and
MSEA local affiliates may use automated calling techniques and/or text message me on my cellular phone on a periodic basis. Neither
the National Education Association nor any of its affiliates charge for text message alerts. Carrier message and data rates may apply to
such alerts. Text STOP to 84693 to stop receiving NEA messages. Text STOPMSEA to 84693 to stop receiving MSEA and MSEA local affiliate
messages. Text HELP to 84693 or go to nea.org/terms for more info.
Members are automatically opted in to MSEAs members-only and other newsletters. You may opt out at any time by clicking the
unsubscribe link found in every email.
How would you like to receive your MSEA ActionLine magazine? Print Digital copy (email)
Step 2: Support elected officials who support public education
By contributing to our PAC, you help advance policies impacting our students, our members, and public education.
YES! I want to join with other members to elect champions who will pass pro-public education budgets and policy,
fund our contract, and give educators the respect we deserve. I hereby authorize the following contribution to the Fund for
Children and Public Education of NEA, MSEA, and my local association to build a strong voice for educators.
I want to donate $15 $10 $5 $___________ per pay period.
The NEA Fund for Children and Public Education and MSEA and local affiliates collect voluntary contributions from Association
members and use those contributions for political purposes, including, but not limited to, making contributions to and
expenditures on behalf of friends of public education who are candidates for federal, state or local office. I understand that I
am making a joint contribution and that ten percent (10%) of my contribution will go to the NEA Fund, and that the remaining
ninety percent (90%) will be divided equally between the MSEA and local association accounts. Contributions to the Funds are
voluntary; making a contribution is neither a condition of employment nor membership in the NEA, the MSEA or local association,
and members have the right to refuse to contribute without suffering any reprisal. Although the NEA, MSEA and local association
Funds request a donation in the amounts listed above, these are only suggestions. A member may contribute more or less than the
suggested amounts, or may contribute nothing at all, without it affecting their membership status, rights, or benefits in NEA, MSEA
or any of its affiliates.
Contributions to the Funds are not deductible as charitable contributions for federal or state income tax purposes. Federal law
requires us to use best efforts to report the name, mailing address, occupation, and name of employer for each individual whose
contributions aggregate in excess of $200 in a calendar year. Only U.S. citizens or lawful permanent residents may contribute to the
Funds.
With full knowledge of this information, I agree that my authorization for political pledges as indicated by the check mark herein
and my authorization for payroll deductions, shall continue in force from year to year unless revoked or modified by me providing
written notification to my local association.
______________________________________________________ ________________________________
SIGNATURE DATE
MONTHLY DUES DEDUCTION FULL TIME HALF-TIME PAC
(for office use only)
__________ deductions by payroll. $_________/per pay $_________/per pay $_________/per pay
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