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Worksheet Foundation Information ------------------------------------------------------------------------------------------- Cluster Map ------------------------------------------------------------------------------------------------------------
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Goals for Year 2012
Goals for Year 2013
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22 - 26.
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• • • • • • • •
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NORTH CAROLINA ASSOCIATION OF EDUCATORS NATIONAL EDUCATION ASSOCIATION 2011-2012 ENROLLMENT FORM
LOCAL SCHOOL NAME
FILL OUT COMPLETELY
School ID:
SOCIAL SECURITY NUMBER
LAST NAME
FIRST NAME
MIDDLE INITIAL ❑ Mr. ❑ Mrs.
❑ Miss ❑ Ms.
❑ Dr.
MEMBERSHIP CODE
ANNUAL PAYMENT
NEA
ADDRESS CITY STATE
ZIP
NCAE
HOME EMAIL HOME PHONE
ASSOCIATION
0
NCAE LOCAL
(
POSITION CODE
MOBILE PHONE
) SUBJECT CODE
(
NCAE-PAC/NC Foundation (Optional)
) DUES ARE NOT REFUNDABLE
ETHNIC CODE
CREDIT CARD MEMBERS
For quicker and more secure credit card processing go to www.ncae.org and enroll online.
CARDHOLDER NAME _________________________________________________________ ACCOUNT NO. _______________________________________________________________ I authorize NCAE to charge $_______________ for membership dues to my credit card account for the 2010-2011 membership year.
SIGNATURE
________________________________________ EXPIRES _______________
MEMBER’S SIGNATURE
DATE
*$40.00
NCAE DIVISION TOTAL METHOD OF PAYMENT ❑ PAYROLL ❑ VISA/MC
❑ CHECK
Payroll Monthly Deduction: $ ____________ No. of Deductions:
____________
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. card members may write a separate check payable *Credit to NCAE-PAC.
LOCAL ASSOCIATION REPRESENTATIVE
PAYROLL DEDUCTION AUTHORIZATION I hereby authorize my employer to deduct from my salary, in accordance with the agreed upon payroll deduction procedure, my membership dues as revised annually in the amounts indicated above for the 2011-2012 membership year and as revised each membership year thereafter, provided that I may revoke this authorization within 15 days after the first payroll deduction of any year by giving written notice to my local association to that effect on or before that date. If for any reason, excepting death, my employment is terminated, or I am on leave of absence, amounts still owing under this authorization shall be deducted from final pay due. I understand that I am not eligible for any Legal Services until after September 1, 2011. By my signature, I indicate that I have read and understand the terms of this agreement. MEMBERSHIP ENROLLMENT SHALL CONTINUE EACH YEAR UNTIL I NOTIFY MY LOCAL UNIT OTHERWISE
❑ Check here for early enrollment. As a participant in the NCAE/NEA AND LOCAL association Early Enrollment Membership Incentive Plan, I am eligible to receive–prior to September 1,
2012 but in no event before April 1, 2012–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 2012-2013 membership year in accordance with the 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, 2012. PAYROLL MEMBER’S SIGNATURE
DATE
The North Carolina Association of Educators, the NCAE-PAC and the National Education Association Fund for Children and Public Education 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, or in the case of the NCAE-PAC and the local PAC, state and local office. Only U.S. citizens or lawful permanent residents may contribute to the NEA or NCAE Fund. Contributions to the NCAE-PAC, the local PAC, and the NEA Fund for Children and Public Education 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. Although the NCAE-PAC, the local PAC and the NEA Fund for Children and Public Education request an annual joint contribution of $40.00 this is only a suggestion. A member may contribute more or less than the suggested amount, or may contribute nothing at all, without it affecting his or her membership status, rights, or benefits in the NEA or the North Carolina Association of Educators. Members who do not wish to contribute the suggested amount of $40.00 but do wish to make a contribution of a different amount should make their contributions to the PAC, the local PAC and the NEA Fund for Children and Public Education by personal check or credit card. The suggested amount of $40 includes a $4 tax deductible contribution to the NC Foundation for Public School Children. The Foundation assists North Carolina schools and students during times of need. Members can also make a separate contribution to the NC Foundation for Public School Children. Contributions or gifts to the NCAE-PAC, the local PAC, and the NEA Fund for Children and Public Education are not deductible for federal income tax purposes. Federal law requires us to use our best efforts to collect the name, mailing address, occupation, and the name of employer of individuals whose contributions aggregate in excess of $50 in an election cycle. Federal law prohibits the NEA Fund for Children and Public Education from receiving donations from persons other than members of the 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. I hereby authorize my employer to continue to deduct from my salary as a voluntary contribution to the PAC, my local association’s PAC, and the NEA FCPE the guideline amount for such contributions proposed annually. I understand that the amount deducted for such voluntary contributions will be divided between the NCAE-PAC, the local association PAC, and the NEA PAC on a 1/3, 1/3, 1/3 basis. This authorization shall remain in effect unless revoked by me in writing to my local association.
SIGNATURE
DATE
NAME ____________________________________________ ADDRESS______________________________________________________________________ OCCUPATION______________________________________ NAME OF EMPLOYER____________________________________________________________ SOCIAL SECURITY # ______________________________________________
OR
NEA MEMBER ID #_________________________________________
NCAE LOCAL ASSOCIATION OR COUNTY ____________________________________________________________________________________________ HOME E-MAIL ADDRESS (No school accounts)__________________________________________________________________
2011-2012 LOCAL MEMBERSHIP WORKSHEET LOCAL:______________ SCHOOL NAME: _____________________ BLD NO.:__________ TEACHER - FULL-TIME ESP - FULL-TIME ADMINISTRATOR ASSOCIATION
NEA NCAE
MEMBERSHIP CODE
ANNUAL PAYMENT
AC-1-100 AC-1-100
415.00
ASSOCIATION
NEA NCAE
MEMBERSHIP CODE
ANNUAL PAYMENT
AC-2-100 AC-2-100
225.00
NCAE LOCAL
NCAE LOCAL PAC (optional)
40.00
NCAE DIVISION
N/A
NEA NCAE
MEMBERSHIP CODE
AC-1-100 AC-1-101
PAC
40.00
(optional)
PAC (optional)
40.00
NCAE DIVISION NCAE DIVISION
*5.00
*30.00
*Required TOTAL
TEACHER – PART-TIME ASSOCIATION
MEMBERSHIP CODE
NEA NCAE
AC-1-50
-Assistant to a: Teacher, Special Ed Instructor, or Librarian. -Custodian, Secretary, Office Assistant, Food Services, Bus Driver, Mechanic, Security Services, etc.
ANNUAL PAYMENT
Principal, Assistant Principal, Superintendent, Administrator, Supervisor, Director, Curriculum Specialist, etc.
TEACHER -STUDENT SERVICES ASSOCIATION
AC-1-50
MEMBERSHIP CODE
ESP - PART-TIME
217.50
ASSOCIATION
MEMBERSHIP CODE
ANNUAL PAYMENT
NEA NCAE
PAC (optional)
40.00
NEA NCAE
122.75
NCAE LOCAL
N/A
TOTAL
Part-time (50% or less) Classroom Teacher, Coach, Instructional Specialist, etc.
AC-2-50 AC-2-50
PAC (optional)
40.00
NCAE DIVISION
*5.00
*Required
MEMBERSHIP CODE
ANNUAL PAYMENT
197.50
*5.00
TOTAL Media Specialist, Tech Facilator, Counselor, Psychologist, Social Wk, Nurse, Physical Therapist, Occupational Therapist
RESERVE - FORMER ESP ASSOCIATION
MEMBERSHIP CODE
NEA NCAE
RS-2-0
RS-1-0 AS-0-0
NCAE DIVISION
*(required)
Part-time (50% or less)
RESERVE - FORMER ACTIVE
40.00
(optional)
NCAE LOCAL
TOTAL
AC-2-50
SUBSTITUTE ASSOCIATION
MEMBERSHIP CODE
NEA NCAE
SB-0-0
ANNUAL PAYMENT
102.75
NCAE LOCAL
(optional)
415.00
PAC
NCAE DIVISION
PAC
ANNUAL PAYMENT
AC-1-100 AC-1-102
NCAE LOCAL
NEA NCAE
415.00
TOTAL
Classroom Teacher, Coach, Instructional Specialist, etc.
ASSOCIATION
ANNUAL PAYMENT
NCAE LOCAL
*Required
TOTAL
ASSOCIATION
SB-0-0
ANNUAL PAYMENT
74.25
NCAE LOCAL
40.00
TOTAL
Former Teacher (AC-1-100 or AC1-50) on leave
NCAE LOCAL PAC (optional)
NCAE DIVISION
40.00
PAC (optional)
NCAE DIVISION
N/A
40.00 N/A
TOTAL TOTAL
Former ESP on leave. NO division.
Hired on a day-to-day basis.
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