Issue link: http://digital.copcomm.com/i/573808
22 Fall 2015 | AEA Advocate ARIZONA EDUCATION ASSOCIATION ENROLLMENT FORM AMPHITHEATER EA Name: SSN: Empl ID: Address: Work Location: City State Zip: Gender: Home Phone: Ethnicity: Mobile Phone: Birth Date: Home E-mail: Registered Voter? Yes No Work E-mail: Democrat Republican Independent None Please update above information. Certified Full Time Part Time # Hours Per Week:_____ Subject:____________________________ Classified Full Time Part Time # Hours Per Week:_____ Position:____________________________ Payment Method # of Deductions Certified Amount* Classified Amount* PAYROLL EFT (ATTACH VOIDED CHECK) Routing# Account# CREDIT CARD (MC, VISA, AMEX, DISC) Card# Recurring charge on the 10th of each month Exp. Date One-time charge CHECK * Deduction amounts are based on full time employment and are valid through Aug 31, 2016. Amounts may vary based on date signed, employment status and/or prior membership status. Any rejected credit card or EFT payment will result in that amount being added to your next scheduled deduction amount. Your regular scheduled deduction amount will resume the following deduction date. Please note that EFT deductions occur twice per month. ATTACH VOIDED CHECK EVERY MEMBER OPTION (EMO): AEA annual dues include an EMO assessment in the amount of $12 for all active members working one-half time or more, which shall be distributed as follows: $5 for AEA Foundation for Teaching and Learning (Foundation), $4 for AEA Fund for Public Education (AEA Fund), and $3 for the AEA Education Improvement Fund (AEA EIF). AEA-Retired members and those active members working less than one-half time shall have an EMO of $6, distributed as follows: $2.50 for AEA Foundation, $2 for AEA Fund, and $1.50 for the AEA EIF. Since 1997, the AEA Foundation has supported teaching and learning in Arizona through over $370,000 in student scholarships, professional development, opportunities and grants for innovative classroom projects. The AEA Fund and the AEA EIF collect voluntary contributions from Association members and their immediate family members who are U.S. citizens or lawful permanent residents for political purposes, including, but not limited to, supporting legislative initiatives and propositions that further the improvement of education in Arizona and making expenditures to and on behalf of friends of public education who are candidates for state office. All contributions to the AEA Fund and the AEA EIF are voluntary and not a condition of employment nor membership in the Association, and members have the right to refuse to contribute without suffering any reprisal. Members desiring a refund from EMO may request a Refund Request Form by calling 800-352-5411. The member must mail the Refund Request Form to Membership postmarked or hand-delivered within thirty (30) days of signing this enrollment form. The Arizona Education Association will mail a refund check after receipt of the Refund Request Form. Dues payments are not deductible as charitable contributions for federal income tax purposes but may be deductible as a miscellaneous itemized deduction, other than the 2.83 percent of their AEA dues attributable to lobbying expenses on the state and national level. With full knowledge of the above, I agree to become a member of the AEA and to subscribe to its goals and objectives and to abide by its Constitution and Bylaws. I authorize payment of my membership dues as revised annually in the payment method selected. I understand my membership will be automatically renewed each year, and the appropriate amount will be deducted per the schedule adopted, unless I revoke this authorization in writing on or before Sept. 1 of any year. I understand AEA legal services are only available for matters that occur after I became a member. Signature: Date: 602-264-1774 | 800-352-5411 | 345 E Palm Lane, Phoenix, AZ 85004-1532 | www.arizonaea.org