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USEA / NEA MEMBERSHIP APPLICATION

Gender (optional)

Female

Male

Other

What is your salary range?

Tier 1 - $16,000 or less

Tier 2 - $16,001 - $22,000

Tier 3 - $22,001 and up

Registered Voter? (optional)

Yes

Hours Worked per Week

10 hours or less per week

10.1 - 20 hours per week

More than 20 hours per week

Media and Text release 1. I hereby grant permission to USEA and NEA to use all images of me recorded by video, audio, or still photography from USEA and NEA related functions. I understand the USEA and NEA have the right to edit and use my image or recording as they see fit, including on social media and print. I understand that there is no obligation to use my appearance. 2. I authorize USEA and NEA to send me occasional text messages.

Media Opt-In

Text Opt-In

Payment Information

EFT - Electronic Funds Transfer (NOTE: A USEA Representative will contact you shortly to collect payment information)

Payroll Deduction (Please accept the Payroll Deduction Opt-In below)

I hereby authorize the District to deduct dues for the Utah School Employees Association and its local and national affiliates as may be established and certified from time to time by those organizations, from my pay each month and to remit those dues to USEA. By signing this application I understand and agree that: this authorization to deduct dues may be revoked by submitting a written revocation to the District; such revocation does not terminate membership in USEA or in its local or national affiliates or the obligation to pay monthly dues, and; my membership in USEA and its local and national affiliates continues until a written notice of cancellation is received at the main office of USEA or until it is otherwise terminated pursuant to bylaws, policies, or procedures of those organizations.

Telephone Consumer Protection Act (TCPA) Consent – By providing my phone number, I understand that the National Education Association and its affiliates including the Utah School Employees Association, the local association, NEA Member Benefits and NEA360 may use automated calling techniques and/or text message me on my cellular phone on a periodic basis. The National Education Association, the Utah School Employees Association and the local association will never charge for text message alerts. Carrier message and data rates may apply to such alerts.

YES to Membership Commitment – I want to join with my fellow employees and become a member of the Utah School Employees Association, my local association and the National Education Association. I hereby request and voluntarily accept membership in these associations and agree to abide by the Constitution and Bylaws of all associations. I hereby designate USEA and its local and national affiliates as my exclusive bargaining representatives. I authorize USEA and/or its designee to contact my employer for the purpose of securing verification of my gross annual salary/pay and information related to my benefits (i.e. Health Insurance coverage, leave, etc.). I also authorize USEA to request my contact information including, but not limited to, my physical address, mailing address, phone number, email, work location, hours worked, etc. Ethnic Minority information is optional and failure to provide it will in no way affect your membership status, rights, or benefits in NEA, USEA or any of their affiliates. This information will be kept confidential. Dues payments are not deductible as charitable contributions for federal income tax purposes.

I UNDERSTAND THIS AGREEMENT IS VOLUNTARY AND IS NOT A CONDITION OF EMPLOYMENT AND THAT I HAVE THE LEGAL RIGHT TO REFUSE TO SIGN THIS AGREEMENT WITHOUT SUFFERING ANY REPRISAL.

I UNDERSTAND THAT CLICKING SUBMIT CONSTITUES A LEGAL DIGITAL SIGNATURE CONFIRMING MY UNDERSTANDING AND AGREEMENT TO ALL OF THE TERMS ABOVE, AND MY CONSENT TO ENGAGE IN THIS TRANSACTION BY ELECTRONIC MEANS.

Thank you for joining USEA! A representative will be in touch if any additional information is required.

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USEA / NEA MEMBERSHIP APPLICATION