SPALC E-Form

Support Personnel Association of Lee County Affiliated with the Florida Education Association 6830 International Center Blvd. Fort Myers, FL 33912 239-275-8252 (office) 239-275-7829 (fax)

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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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Home Phone

Mobile Phone

Preferred Phones

preferred

Personal E-mail *

Work E-mail

Work Location

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last four of your S.S.

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Employee Identification No.

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Recruiter - Member Organizer name

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Worksite Location

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Select your membership category

Dues Amount

$0.00

Total * draft

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Authorize

Payroll Deducation.

I hereby agree to pay, and authorize my employer to deduct, the dues assessments described above and as are certified by the Association to 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 School Board and Association notifying them of such revocation as provided by law.

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