ESCAMBIA EDUCATION ASSOCIATION
UNION OF ESCAMBIA ESP
Affiliated with FEA, NEA & AFT
6551 N. Palafox Hwy.
Check One:
Escambia Education Association
Thefollowingin
formationisrepresentedintheformofcodes.Pleaseplacetheappropriate
codeinthe(SEECODES)areaofthisform.
Pensacola, FL 32503
(850) 476-2906
LASTNAME
Escambia ESP
FIRSTNAME MI
SEECODES
SUBJECTAREA
01 AdultBasicEducation
02 Agriculture
03 Architecture
04 AreaStudies
05 Art
06 BiologicalStudies
07 Business
08 Communications
09 ComputerScience
10 DriverEducation
11 Education
12 Engineering
13 English/LanguageArts
14 Fine&AppliedArts
15 ForeignLanguage&Lit.
16 Forestry
17 Geography
18 Health&Phys.Ed.
19 HealthProfessions
20 Fam&ConsumerScience
21 IndustrialArt
24 LibraryScience
25 Mathematics
26 MilitaryScience
27 Music
29 PhysicalScience
30 Psychology
31 PublicServicesCurric.
32 Reading
34 Science
35 SocialSciences
36 SocialStudies
37 SpecialEducation
38 Speech&Drama
39 VocationalEducation
POSITION
01 AudioVisualTechnician
02 CafeteriaWorker
03 ClassroomTeacher
04 Coach
05 Counselor
06 Custodian
08 Librarian
09 MaintenancePersonnel
10 OfficeSupport/Secretary
11 Principal/Asst.Principal
13 SpeechPathologist/
HearingImpaired
14 Supervisor/Director
18 TeacherAide
19 TransportationPersonnel
21 Admin.OfficePersonnel
99 Other
LEVEL
01 Preschool/Kindergarten
02 Elementary
03 Middle
04 High
05 VocationalEducation
09 CentralSite/AdminCenter
99 Other
ETHNIC*
1 AmericanIndian/Alaska
Native
3 Black
4 Hispanic
5 Caucasian
(notofSpanishOrigin)
6 Asian
7 NativeHawaiian/Pacific
Islander
9 Unknown
*Ethnic minority information is
optional and failure to provide it
will in no way affect your mem‐
bershipstatus,rightsorbenefitsin
NEA, AFT, FEA or the Association.
Thisinformationwillbekeptconfi‐
dential.
PAYROLL DEDUCTION AUTHORIZATION: Iherebyagreeto pay, and authorize my employer to
deducttheduesandassessmentsdescribedaboveandasarecertifiedbytheAssociationtothe
SchoolBoardforeachyearthereafterfrommysalaryanddirectandauthorizemyemployerto
paysuchamountstotheAssociationinacc
ordancewithpayrolldeduct
ionproceduresineffect;
provided,however, I may cancelmy membership and this authorization by providing 30days’
written notice to the School Board and the Association notifying them of such revocation as
provided by law. However, if I receive a membership incentive (dues rebate or a
"free months" promotion), I will not withdraw my membership during the first 12
months without reimbursing EEA or Union of Escambia ESP for said incentives.
90 NosubjectTaught
91 GeneralSubjects
99 Other
Escambia Education Association
Union of Escambia ESP
6551 N Palafox
Pensacola, FL 32503
Phone: 850-476-2906
Fax: 850-477-4341
Email: escambia@floridaea.org
Website: http://www.escambiafea.org
NAME
ADDRESS APT.NO.
CITY&
STATE
ZIPCODE
WORKSITE
JOBTITLE/
CLASSIFICATION
LAST 4 DIGITS OF
SOC. SEC. NUMBER
AREACODE&
HOMEPHONE
HOMEEMAILADDRESS
ETHNIC
CODE
XXX-XX-
Date
Signature Recruiter
DATE OF BIRTH
---select SUBJECT CODE---
---select POSITION CODE---
---selece LEVEL CODE---
--- Gender ---
---select ETHNIC CODE---
click to sign
signature
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