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POLK EDUCATION ASSOCIATION MEMBERSHIP/PAYROLL DEDUCTION CARD
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Your Partner. Your Advocate. Your Association.
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First Name
*
Middle Name
Last Name
*
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Mailing Country
*
United States of America
Mailing Address
*
Mailing Suite
Mailing City
*
Mailing State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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
West Virginia
Wisconsin
Wyoming
Mailing Zip Code
*
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Personal E-mail
*
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Job Title (Pick one that most represents your work)
*
Job Title (Pick one that most represents your work)
Education Support Professional
Paraeducator
Classroom Teacher
Special/Developmental
Counselor
Media Specialist
Speech/Hearing
Psychologist
Reading Specialist
Coach
Occ. Therapist/Physical Therapist
Non-Classroom Teacher
Other
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What year did you enter the profession?
*
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I am:
*
I am:
Transferring from another school district
Joining the Association today
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What is your SAP Number?
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What is your Shirt Size?
*
What is your Shirt Size?
Small
Medium
Large
X-Large
XX-Large
3X-Large
4X-Large
5X-Large
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What is your worksite?
*
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What is your Birthday?
*
Date
E.g., 2023-03-30
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What is your Mobile phone number?
*
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What is you home phone number?
*
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Please provide the last 4 digits of your Social Security Number
*
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Who recruited you to PEA?
payroll-deduction
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Select your membership category
Select your membership category
Paraeducator
Secretary/Educational Support Personnel
Instructional
Dues Amount
$0.00
Total
* draft
privacy-policy
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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.
Print your name
Date
Date
E.g., 2023-03-30
Signature field is required
CAPTCHA
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