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personal-information-1
Social Security Number
First Name
*
Middle Name
Last Name
*
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Mailing Country
*
United States of America
Mailing Address
*
Mailing City
*
Mailing State
*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Illinois
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
US Virgin Island
Washington
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Wisconsin
Wyoming
Mailing Zip Code
*
personal-information-2
Date of Birth
Date
E.g., 2023-03-29
Home Phone
Mobile Phone
Work Phone
Preferred Phones
preferred
preferred
preferred
Personal E-mail
*
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Position
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Registered Voter
Yes
No
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Work location
*
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Select your membership category
Select your membership category
payroll deduction
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Authorize
Payroll Deduction:
I hereby agree to pay, and authorize my employer to deduct, the dues and assessments described above and as are certified by the Association of the School Board for each year thereafter from my salary and direct and authorize my employer to pay such amounts to the Association in accordance with payroll deduction procedures in effect; provided, however, I may cancel my membership and this authorization by providing 30 days’ written notice to the Association notifying them of such revocation as provided by law.
Print your name
Date
Date
E.g., 2023-03-29
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