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ESCAMBIA EDUCATION ASSOCIATION

UNION OF ESCAMBIA ESP

Affiliated with FEA, NEA & AFT

6551 N. Palafox Hwy.

Check One:

Escambia Education Association

Thefollowingin

formationisrepresentedintheformofcodes.Pleaseplacetheappropriate

codeinthe(SEECODES)areaofthisform.

Pensacola, FL 32503

(850) 476-2906

LASTNAME

Escambia ESP

FIRSTNAME MI

SEECODES

SUBJECTAREA

01 AdultBasicEducation

02 Agriculture

03 Architecture

04 AreaStudies

05 Art

06 BiologicalStudies

07 Business

08 Communications

09 ComputerScience

10 DriverEducation

11 Education

12 Engineering

13 English/LanguageArts

14 Fine&AppliedArts

15 ForeignLanguage&Lit.

16 Forestry

17 Geography

18 Health&Phys.Ed.

19 HealthProfessions

20 Fam&ConsumerScience

21 IndustrialArt

24 LibraryScience

25 Mathematics

26 MilitaryScience

27 Music

29 PhysicalScience

30 Psychology

31 PublicServicesCurric.

32 Reading

34 Science

35 SocialSciences

36 SocialStudies

37 SpecialEducation

38 Speech&Drama

39 VocationalEducation

POSITION

01 Audio‐VisualTechnician

02 CafeteriaWorker

03 ClassroomTeacher

04 Coach

05 Counselor

06 Custodian

08 Librarian

09 MaintenancePersonnel

10 OfficeSupport/Secretary

11 Principal/Asst.Principal

13 SpeechPathologist/

HearingImpaired

14 Supervisor/Director

18 TeacherAide

19 TransportationPersonnel

21 Admin.OfficePersonnel

99 Other

LEVEL

01 Preschool/Kindergarten

02 Elementary

03 Middle

04 High

05 VocationalEducation

09 CentralSite/AdminCenter

99 Other

ETHNIC*

1 AmericanIndian/Alaska

Native

3 Black

4 Hispanic

5 Caucasian

(notofSpanishOrigin)

6 Asian

7 NativeHawaiian/Pacific

Islander

9 Unknown

*Ethnic minority information is

optional and failure to provide it

will in no way affect your mem‐

bershipstatus,rightsorbenefitsin

NEA, AFT, FEA or the Association.

Thisinformationwillbekeptconfi‐

dential.

PAYROLL DEDUCTION AUTHORIZATION: Iherebyagreeto pay, and authorize my employer to

deducttheduesandassessmentsdescribedaboveandasarecertifiedbytheAssociationtothe

SchoolBoardforeachyearthereafterfrommysalaryanddirectandauthorizemyemployerto

paysuchamountstotheAssociationinacc

ordancewithpayrolldeduct

ionproceduresineffect;

provided,however, I may cancelmy membership and this authorization by providing 30days’

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 NosubjectTaught

91 GeneralSubjects

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

ZIPCODE

WORKSITE

JOBTITLE/

CLASSIFICATION

LAST 4 DIGITS OF

SOC. SEC. NUMBER

AREACODE&

HOMEPHONE

HOMEEMAILADDRESS

ETHNIC

CODE

XXX-XX-

Date

Signature Recruiter

DATE OF BIRTH

---select SUBJECT CODE---

---select POSITION CODE---

---selece LEVEL CODE---

--- Gender ---

---select ETHNIC CODE---

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PAYROLL DEDUCTION AUTHORIZATION (Escambia Education Association)

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