POLK EDUCATION ASSOCIATION MEMBERSHIP/PAYROLL DEDUCTION CARD

Your Partner. Your Advocate. Your Association.

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First Name *

Middle Name

Last Name *

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Mailing Country *

Mailing Address *

Mailing Suite

Mailing City *

Mailing State *

Mailing Zip Code *

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Personal E-mail *

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Job Title (Pick one that most represents your work) *

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What year did you enter the profession? *

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I am: *

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What is your SAP Number?

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What is your Shirt Size? *

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What is your worksite? *

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What is your Mobile phone number? *

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What is you home phone number? *

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Who recruited you to PEA?

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Select your membership category

Dues Amount

$0.00

Total * draft

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Authorize

I authorize my employer, The Polk County School Board of Polk County Florida, to deduct the amount indicated and remit same as instructed by the Association.

I understand that the deduction amount may change and consent to such change without the necessity of additional authorization. This authorization may be revoked with a thirty (30) day written notice to the Polk Education Association.

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$0.00