National Education Association and Nebraska State Education Association 605 S. 14
th
Street, Lincoln, NE 68508-2742
Fax: 1-402-475-2630 E-Mail: membership@nsea.org
Required fields shown in red. Failure to complete will delay processing of your membership.
NAME LOCAL ASSOCIATION
LAST 4 DIGITS - SOCIAL SECURITY NUMBER EMPLOYER NAME
DATE OF BIRTH BUILDING NAME
ADDRESS WORK PHONE
CITY STATE ZIP WORK E-MAIL
HOME PHONE (Landline) HIRE DATE
CELL PHONE TEXT?
7
____ YES ____NO
Were you a member in 2018-2019? _____YES _____NO
HOME E-MAIL If yes, indicate the Local Association
Payment Method
Check in Full (pay after August 1
st
)
Credit Card in Full
(enter CC info on back-will be
processed after August 1
st
)
EFT (Electronic Funds Transfer)
(October – July bank draft)
Complete authorization below.*
*Membership will not be processed until
EFT banking authorization is received.
Position
Teacher
Subject Area: _______________
Counselor
Education Support Professional
Position: ___________________
Administrator*
* (Directly hires, evaluates, transfers, disciplines or dismisses)
Level
PK-12
Higher Ed
Gender
Male
Female
Ethnic Group
3
American Indian/Alaska Native
Asian
Black
Caucasian (not of Spanish origin)
Hispanic
Multi-Ethnic
Native Hawaiian/Pacific Islander
Other
Unknown
Registered Voter
Yes
No
Political Party
Democrat
Independent
Republican
Other
EFT
(Electronic Funds Transfer
)
Bank Draft Authorization
(Complete this
authorization
or attach a voided check.)
Checking
Savings
*Note: Do not use deposit slips for banking information.
Bank Name:
Bank Routing Number (9 digit):
Bank Account Number
Please select your membership category and mark one appropriate box. Write dues amount in gray box.
Professional Category and NSEA/NEA Dues
PK-12 Teachers, school administrators, and substitutes with a teaching
certificate who work for a public educational institution; higher ed faculty
and adjunct professors
6
.
Education Support Professional Category and NSEA/NEA Dues:
Custodians, bus drivers, para-educators, secretaries, cooks, and other support personnel
who work for a public educational institution; and higher ed academic professionals or
support staff.
Full Time (more than 50%)
$609.00
My ESP annual salary is $
3
2
,
676
or above
$
532.50
Half Time (50% or less)
$316.00
My ESP
annual salary is between $2
6
,
140
and $
32.675
$
491.20
Quarter Time (25% or less)
$273.00
My ESP annual salary is between $
19,606
and $
26,139
$
360.60
Substitute (not under contract – liability only)
$118.25
My ESP annual salary is between $13,070 and $19,605 $278.00
Substitute (under contract)
$273.00
My ESP annual salary is between $6,535 and $13,069 $171.40
My ESP annual salary is $6,534 or less $ 88.80
ESP Substitute
$
150.75
1
Dues: NSEA POLITICAL ACTION FUNDS AND REFUNDS: NSEA is actively involved in financial support for recommended candidates for state and local office. NSEA's political action
program is supported by voluntary contributions collected with the membership dues. This year's contribution is $15.00 for full-time active members and $7.50 for half-time and active substitute
members. Individuals in other membership classifications make no PAC contributions. Any NSEA member may request a refund of their contribution for the current membership year. Refunds
are made after January 1 of each year, upon written request from an individual member. A refund notice will appear in the NSEA Voice. Membership is open only to those who agree to
subscribe to the goals and objectives of the Association and to abide by its constitution and bylaws.
2
The NEA FUND: The NEA Fund for Children and Public Education (NEA-FUND) collects voluntary contributions from Association members which are used 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 office. Only U.S. citizens or lawful permanent residents may
contribute to the NEA Fund. Contributions to the NEA Fund are voluntary; making a contribution is neither a condition of employment nor membership in the Association, and members have
the right to refuse to contribute without suffering any reprisal.
Contributions to the NEA Fund are not deductible as charitable contributions for federal income tax purposes.
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of the employer for each individual whose contributions aggregate in excess
of $200 in a calendar year. Federal law prohibits The NEA Fund from receiving donations from persons other than members of NEA and its affiliates, and their immediate families. All donations
from persons other than members of NEA and its affiliates, and their immediate families, will be returned forthwith.
2019-2020 MEMBER ENROLLMENT AUTHORIZATION: In exchange for membership benefits as provided by NSEA policies and bylaws, I agree to pay to the NSEA the full amount of annual
dues and/or contributions indicated above. This Agreement shall automatically renew each school contract year, and I agree to accept and pay any changes in the amount of dues and/or
contributions officially adopted by the respective governing bodies upon certification in writing by the local association unless such renewal is revoked in writing to the local association.
I agree by signing below that I will pay the total annual dues by the payment method indicated above. I acknowledge that the revocation of my authorization for a payment method does
not revoke my obligation to pay the total dues amount unless notice is otherwise provided. I affirm that the above information is accurate to the best of my knowledge.
I UNDERSTAND THAT THIS AGREEMENT IS VOLUNTARY AND IS NOT A CONDITION OF EMPLOYMENT AND THAT I HAVE THE LEGAL RIGHT TO REFUSE TOSIGN THIS AGREEMENT WITHOUT SUFFERING ANY REPRISAL.
AUTHORIZATION SIGNATURE_________________________________________________________________________________________ DATE_______________________
(Please read note 5 on back, if dated before September 1st)
Dues
1
NEA
4
/NSEA
Local
NEA-FUND
2
Local PAC
TOTAL
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.
Enrolled by (name):
0
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signature
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EXPLANATIONS
3
Ethnic Group
Ethnic minority information is optional, and failure to provide it will in no way affect your membership status, rights or benefits in
NEA, NSEA or any of their affiliates. The information will be kept confidential. This data is collected to ensure ethnic minority
guarantees in the governance of the Association.
4
NEA Life Members
NEA Life members need to subtract the appropriate NEA dues amount from the amounts listed on the front. Specific information
is available from the Organizational Specialist or the NSEA Membership department 1-800-742-0047.
5
Dated before September 1, 2019
As a participant in the NSEA/NEA Early Enrollment Membership Incentive Plan, I am eligible to receive -- prior to September 1,
2019, but in no event before April 1, 2019 -- benefits under the NEA Educators Employment Liability (EEL) Program, as well as
access to select NEA Member Benefits programs.
As a condition of eligibility for these benefits, I agree to pay the appropriate unified Active membership dues for the 2019-2020
membership year in accordance with established payment procedures. Should I fail to do so, my eligibility to receive benefits
under the NEA EEL Program shall immediately terminate. In addition, I shall become liable for the cost of any benefits that were
provided to me under the NEA EEL Program prior to September 1, 2019.
6
Higher Ed Adjunct Professors
An adjunct professor is a part-time professor who does not hold a permanent position at that particular academic
institution. Dues are based on a part-time Active Professional level, depending on the number of hours worked.
7
Texting
I hereby consent to receive autodialed and/or pre-recorded telemarketing calls or text messages from or on behalf of the
Nebraska State Education Association (and/or NSEA’s affiliates) at the telephone number provided on the application, including
my wireless number, if applicable. Carrier message and data rates may apply to such communications. Reply STOP to any
message received to discontinue receiving calls and/or text messages from the NSEA. I understand that this consent is not a
condition of membership with the NSEA.
Sample EFT Banking Information Location
CREDIT CARD AUTHORIZATION FORM
Type of Card: ___Visa ___Mastercard ___Discover
Cardholder Name (as shown on card):
Credit Card Number:
Expiration Date (mm/yy):
3-Digit Security Code (back of card):
Credit Card Billing Address/City/State/Zip (Only needed if different from the front of this application)
I authorize the charge of my credit card for the full payment of dues.
Authorization Signature Date
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signature
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