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537791
THE PENNSYLVANIA STATE EDUCATION ASSOCIATIONNATIONAL EDUCATION ASSOCIATION
2010 ENROLLMENT FORM 2011EMANGNIDLIUBREYOLPMELANOITACUDE/EMANNOITAICOSSALACOLREBMUNNOITAICOSSALACOL
SS# OR PSEA ID# TITLEMRS.MISSMS.
MR.DR.
LAITINIELDDIMEMANTSRIFEMANTSAL
STREET ADDRESS EDOCPIZETATSYTIC
01 Preschool02 Kindergarten
03 Elementary04 Middle Sch/Jr Hg
05 High School06 Community/Junior College/Two-Year Associate Degree
07 College08 University
09 OtherEMPLOYMENT LEVEL ( ) PLEASE CHECK ONE
EMPLOYMENT CODES: ( ) PLEASE CHECK ONE
101 Adult Ed102 Art103 Business Ed104 Coach105 Communications106 Computer Science107 Driver Ed108 English/
Language Arts109 Foreign Language
& Literature110 Health &
Physical Education111 Family &
Consumer Sciences112 Library Science113 Mathematics
Classroom Teacher114 Music115 Reading116 Science117 Social Studies118 Speech Therapist120 Technology Ed.121 General Subject122 No Subject123 Other124 Gifted125 Special Education126 Athletic Trainer127 English as
Second Language128 Literacy Coach129 Alternative Ed
Academic Areas201 Agriculture202 Business203 Distributive205 Family &
Consumer Sciences206 Technology Education207 Trade and Industrial208 Other/Votech209 Nursing Educator210 Physical Therapy
Educator211 Occupational
Therapy Educator
Career/Technical Studies301 Agriculture302 Architecture303 Biology304 Business305 Communications306 Computer Science307 Education308 Engineering309 English310 Foreign Languages311 Geography313 Family &
Consumer Sciences314 Law315 Library
Higher Ed316 Mathematics317 Military Science318 Philosophy319 Physical
Science320 Psychology321 Religion322 Social Science323 No Subject324 Other325 Nursing Educator326 Physical
Therapy Educator327 Occupational
Therapy Educator
401 Chief/AssistantAdministrator
402 Supervisor403 Other
Administration404 Principal405 Assistant
Principal
Administration/Supervision601 A-V Technician602 Custodian603 Maintenance
Personnel604 Food Service605 Secretarial/Clerical606 Aide
Non Instructional607 Bus Driver608 Confidential
Personnel610 Other611 Educational
Paraprofessional
ESP
501 Counselor502 Dental Hygienist503 H & S Visitor504 School Nurse505 School Psychologist506 Occupational Therapist507 Physical Therapist
Pupil Services
DATE OF BIRTH
GENDER SCHOOL DISTRICT CODEWHERE YOU LIVE (OVER)
POLITICAL AFFILIATION
AREA CODE HOME TELEPHONE NUMBER
FEMALEMALE
MO DAY YEARREPUBLICAN DEMOCRAT INDEPENDENT NONE
ETHNIC CLASSIFICATION
01 American Indian/Alaska Native02 Asian03 Black
04 Hispanic05 Caucasian06 Biracial
07 Multiethnic08 Native Hawaiian or other
Pacific Islander
PSEA is commited to assuring the equitable representation of members of ethnic minority groups at allgovernance levels of the Association. To help achieve this goal, completion of this section is stronglyencouraged. Failure to do so, however, will not affect your membership status, rights or benefits in NEA,PSEA, the local or any of their affiliates. Ethnic minority shall mean those persons designated as ethnicminority by the U.S. Bureau of Census. This information will be kept confidential.
HOME E-MAIL ADDRESS TNEMYAPDNAEPYTPIHSREBMEM
NOITCUDEDLLORYAPYBEGDELPDNUFAENDNAECAP-AESPSUOUNITNOC
PSEA-PACE for State Elections( ) PLEASE CHECK
NEA Fund for Federal Elections( ) PLEASE CHECK
A.) $52 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
A.) $15 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
)TNUOMARETNE()TNUOMARETNE(
I UNDERSTAND THAT OF THE TOTAL PSEA DUES, $4.50 IS FOR A ONE YEAR SUBSCRIPTION TO THE VOICE, AND OF THE TOTAL NEA DUES $5.65 IS FOR A ONE YEAR SUB-SCRIPTION TO NEA TODAY.
BY SIGNING THIS MEMBERSHIP FORM, I AM ENROLLING FOR THE 2010-2011 MEMBERSHIP YEAR AND ALSO AGREEING TO MAINTAIN MY MEMBERSHIP IN THE APPROPRIATECATEGORY EACH MEMBERSHIP YEAR THEREAFTER. I MAY REVOKE MY MEMBERSHIP BY NOTIFYING, IN WRITING, MY LOCAL ASSOCIATION, WHEN AVAILABLE, OR PSEANO LATER THAN OCTOBER 1 OF THAT MEMBERSHIP YEAR.
DUES PAYMENTS AND CONTRIBUTIONS TO NEA FUND AND PSEA-PACE, IF APPLICABLE, ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL OR STATEINCOME TAX PURPOSES. DUES PAYMENTS OR A PORTION MAY BE DEDUCTIBLE AS A MISCELLANEOUS ITEMIZED DEDUCTION.
SIGNATURE
Local Officer Verification RequiredPLEASE INITIAL
PLEASE RETURN THE FIRST TWO COPIES OF THIS FORM TO PSEA
Pennsylvania is a unified state. The NEA, PSEA and local associations may not be joined separately.Dues cannot be pro-rated.( ) PLEASE CHECK ONEEA MEMBERSHIP
10 Active-Annual12 Active-1/2 Year13 Active- Less Than 500 Hours
21 ESP-Full Time23 ESP-School Year24 ESP-Greater than 2 hours; up to
and including 4 hours25 ESP- Up to and including 2 hours31 ESP-1/2 year Full-time33 ESP-1/2 year School year34 ESP-1/2 year Greater than 2
hours; up to and including 4 hours35 ESP-1/2 yr Up to and including 2 hrs
ESP MEMBERSHIP
SUBSTITUTE18 Substitute (day to day)
ASSOCIATE19 Associate (PSEA only)
PSEA DUES (from above):NEA DUES (from above):
ARBITRATION ASSESSMENT (from above):LOCAL DUES:PSEA-PACE CONTRIBUTION (from pledge):NEA FUND CONTRIBUTION (from pledge):TOTAL PAYMENT:
PSEAREGIONASSESSMENT TOTAL
427.00218.50114.25
213.50109.25
57.00
57.00109.25
57.0031.00
31.00
25.00
25.00
166.0088.0049.25
96.5096.5053.50
32.0053.5053.5032.00
32.00
15.00
593.00306.50163.50
318.50212.75114.40
92.90167.00114.00
64.95
64.95
40.00
25.00
5.504.502.50
2.502.752.251.25
1.25
ARBITRATIONASSESSMENT
3.002.501.40
1.401.501.250.70
0.70
$
$
ETAD/ETAD/
5/10
PDE ID#
500153
0.00
NEA
REGION ASSESSMENT (from above):
INTELLIPRINT SOLUTIONS, INC. HARRISBURG, PA 17111 P8173 CE 5/10
PSEA Copy
537791
THE PENNSYLVANIA STATE EDUCATION ASSOCIATIONNATIONAL EDUCATION ASSOCIATION
2010 ENROLLMENT FORM 2011EMANGNIDLIUBREYOLPMELANOITACUDE/EMANNOITAICOSSALACOLREBMUNNOITAICOSSALACOL
SS# OR PSEA ID# TITLEMRS.MISSMS.
MR.DR.
LAITINIELDDIMEMANTSRIFEMANTSAL
STREET ADDRESS EDOCPIZETATSYTIC
01 Preschool02 Kindergarten
03 Elementary04 Middle Sch/Jr Hg
05 High School06 Community/Junior College/Two-Year Associate Degree
07 College08 University
09 OtherEMPLOYMENT LEVEL ( ) PLEASE CHECK ONE
EMPLOYMENT CODES: ( ) PLEASE CHECK ONE
101 Adult Ed102 Art103 Business Ed104 Coach105 Communications106 Computer Science107 Driver Ed108 English/
Language Arts109 Foreign Language
& Literature110 Health &
Physical Education111 Family &
Consumer Sciences112 Library Science113 Mathematics
Classroom Teacher114 Music115 Reading116 Science117 Social Studies118 Speech Therapist120 Technology Ed.121 General Subject122 No Subject123 Other124 Gifted125 Special Education126 Athletic Trainer127 English as
Second Language128 Literacy Coach129 Alternative Ed
Academic Areas201 Agriculture202 Business203 Distributive205 Family &
Consumer Sciences206 Technology Education207 Trade and Industrial208 Other/Votech209 Nursing Educator210 Physical Therapy
Educator211 Occupational
Therapy Educator
Career/Technical Studies301 Agriculture302 Architecture303 Biology304 Business305 Communications306 Computer Science307 Education308 Engineering309 English310 Foreign Languages311 Geography313 Family &
Consumer Sciences314 Law315 Library
Higher Ed316 Mathematics317 Military Science318 Philosophy319 Physical
Science320 Psychology321 Religion322 Social Science323 No Subject324 Other325 Nursing Educator326 Physical
Therapy Educator327 Occupational
Therapy Educator
401 Chief/AssistantAdministrator
402 Supervisor403 Other
Administration404 Principal405 Assistant
Principal
Administration/Supervision601 A-V Technician602 Custodian603 Maintenance
Personnel604 Food Service605 Secretarial/Clerical606 Aide
Non Instructional607 Bus Driver608 Confidential
Personnel610 Other611 Educational
Paraprofessional
ESP
501 Counselor502 Dental Hygienist503 H & S Visitor504 School Nurse505 School Psychologist506 Occupational Therapist507 Physical Therapist
Pupil Services
DATE OF BIRTH
GENDER SCHOOL DISTRICT CODEWHERE YOU LIVE (OVER)
POLITICAL AFFILIATION
AREA CODE HOME TELEPHONE NUMBER
FEMALEMALE
MO DAY YEARREPUBLICAN DEMOCRAT INDEPENDENT NONE
ETHNIC CLASSIFICATION
01 American Indian/Alaska Native02 Asian03 Black
04 Hispanic05 Caucasian06 Biracial
07 Multiethnic08 Native Hawaiian or other
Pacific Islander
PSEA is commited to assuring the equitable representation of members of ethnic minority groups at allgovernance levels of the Association. To help achieve this goal, completion of this section is stronglyencouraged. Failure to do so, however, will not affect your membership status, rights or benefits in NEA,PSEA, the local or any of their affiliates. Ethnic minority shall mean those persons designated as ethnicminority by the U.S. Bureau of Census. This information will be kept confidential.
HOME E-MAIL ADDRESS TNEMYAPDNAEPYTPIHSREBMEM
NOITCUDEDLLORYAPYBEGDELPDNUFAENDNAECAP-AESPSUOUNITNOC
PSEA-PACE for State Elections( ) PLEASE CHECK
NEA Fund for Federal Elections( ) PLEASE CHECK
A.) $52 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
A.) $15 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
)TNUOMARETNE()TNUOMARETNE(
I UNDERSTAND THAT OF THE TOTAL PSEA DUES, $4.50 IS FOR A ONE YEAR SUBSCRIPTION TO THE VOICE, AND OF THE TOTAL NEA DUES $5.65 IS FOR A ONE YEAR SUB-SCRIPTION TO NEA TODAY.
BY SIGNING THIS MEMBERSHIP FORM, I AM ENROLLING FOR THE 2010-2011 MEMBERSHIP YEAR AND ALSO AGREEING TO MAINTAIN MY MEMBERSHIP IN THE APPROPRIATECATEGORY EACH MEMBERSHIP YEAR THEREAFTER. I MAY REVOKE MY MEMBERSHIP BY NOTIFYING, IN WRITING, MY LOCAL ASSOCIATION, WHEN AVAILABLE, OR PSEANO LATER THAN OCTOBER 1 OF THAT MEMBERSHIP YEAR.
DUES PAYMENTS AND CONTRIBUTIONS TO NEA FUND AND PSEA-PACE, IF APPLICABLE, ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL OR STATEINCOME TAX PURPOSES. DUES PAYMENTS OR A PORTION MAY BE DEDUCTIBLE AS A MISCELLANEOUS ITEMIZED DEDUCTION.
SIGNATURE
Local Officer Verification RequiredPLEASE INITIAL
PLEASE RETURN THE FIRST TWO COPIES OF THIS FORM TO PSEA
Pennsylvania is a unified state. The NEA, PSEA and local associations may not be joined separately.Dues cannot be pro-rated.( ) PLEASE CHECK ONEEA MEMBERSHIP
10 Active-Annual12 Active-1/2 Year13 Active- Less Than 500 Hours
21 ESP-Full Time23 ESP-School Year24 ESP-Greater than 2 hours; up to
and including 4 hours25 ESP- Up to and including 2 hours31 ESP-1/2 year Full-time33 ESP-1/2 year School year34 ESP-1/2 year Greater than 2
hours; up to and including 4 hours35 ESP-1/2 yr Up to and including 2 hrs
ESP MEMBERSHIP
SUBSTITUTE18 Substitute (day to day)
ASSOCIATE19 Associate (PSEA only)
PSEA DUES (from above):NEA DUES (from above):
ARBITRATION ASSESSMENT (from above):LOCAL DUES:PSEA-PACE CONTRIBUTION (from pledge):NEA FUND CONTRIBUTION (from pledge):TOTAL PAYMENT:
PSEAREGIONASSESSMENT TOTAL
427.00218.50114.25
213.50109.25
57.00
57.00109.25
57.0031.00
31.00
25.00
25.00
166.0088.0049.25
96.5096.5053.50
32.0053.5053.5032.00
32.00
15.00
593.00306.50163.50
318.50212.75114.40
92.90167.00114.00
64.95
64.95
40.00
25.00
5.504.502.50
2.502.752.251.25
1.25
ARBITRATIONASSESSMENT
3.002.501.40
1.401.501.250.70
0.70
$
$
ETAD/ETAD/
5/10
PDE ID#
500153
0.00
NEA
REGION ASSESSMENT (from above):
INTELLIPRINT SOLUTIONS, INC. HARRISBURG, PA 17111 P8173 CE 5/10
NEA Copy
537791
THE PENNSYLVANIA STATE EDUCATION ASSOCIATIONNATIONAL EDUCATION ASSOCIATION
2010 ENROLLMENT FORM 2011EMANGNIDLIUBREYOLPMELANOITACUDE/EMANNOITAICOSSALACOLREBMUNNOITAICOSSALACOL
SS# OR PSEA ID# TITLEMRS.MISSMS.
MR.DR.
LAITINIELDDIMEMANTSRIFEMANTSAL
STREET ADDRESS EDOCPIZETATSYTIC
01 Preschool02 Kindergarten
03 Elementary04 Middle Sch/Jr Hg
05 High School06 Community/Junior College/Two-Year Associate Degree
07 College08 University
09 OtherEMPLOYMENT LEVEL ( ) PLEASE CHECK ONE
EMPLOYMENT CODES: ( ) PLEASE CHECK ONE
101 Adult Ed102 Art103 Business Ed104 Coach105 Communications106 Computer Science107 Driver Ed108 English/
Language Arts109 Foreign Language
& Literature110 Health &
Physical Education111 Family &
Consumer Sciences112 Library Science113 Mathematics
Classroom Teacher114 Music115 Reading116 Science117 Social Studies118 Speech Therapist120 Technology Ed.121 General Subject122 No Subject123 Other124 Gifted125 Special Education126 Athletic Trainer127 English as
Second Language128 Literacy Coach129 Alternative Ed
Academic Areas201 Agriculture202 Business203 Distributive205 Family &
Consumer Sciences206 Technology Education207 Trade and Industrial208 Other/Votech209 Nursing Educator210 Physical Therapy
Educator211 Occupational
Therapy Educator
Career/Technical Studies301 Agriculture302 Architecture303 Biology304 Business305 Communications306 Computer Science307 Education308 Engineering309 English310 Foreign Languages311 Geography313 Family &
Consumer Sciences314 Law315 Library
Higher Ed316 Mathematics317 Military Science318 Philosophy319 Physical
Science320 Psychology321 Religion322 Social Science323 No Subject324 Other325 Nursing Educator326 Physical
Therapy Educator327 Occupational
Therapy Educator
401 Chief/AssistantAdministrator
402 Supervisor403 Other
Administration404 Principal405 Assistant
Principal
Administration/Supervision601 A-V Technician602 Custodian603 Maintenance
Personnel604 Food Service605 Secretarial/Clerical606 Aide
Non Instructional607 Bus Driver608 Confidential
Personnel610 Other611 Educational
Paraprofessional
ESP
501 Counselor502 Dental Hygienist503 H & S Visitor504 School Nurse505 School Psychologist506 Occupational Therapist507 Physical Therapist
Pupil Services
DATE OF BIRTH
GENDER SCHOOL DISTRICT CODEWHERE YOU LIVE (OVER)
POLITICAL AFFILIATION
AREA CODE HOME TELEPHONE NUMBER
FEMALEMALE
MO DAY YEARREPUBLICAN DEMOCRAT INDEPENDENT NONE
ETHNIC CLASSIFICATION
01 American Indian/Alaska Native02 Asian03 Black
04 Hispanic05 Caucasian06 Biracial
07 Multiethnic08 Native Hawaiian or other
Pacific Islander
PSEA is commited to assuring the equitable representation of members of ethnic minority groups at allgovernance levels of the Association. To help achieve this goal, completion of this section is stronglyencouraged. Failure to do so, however, will not affect your membership status, rights or benefits in NEA,PSEA, the local or any of their affiliates. Ethnic minority shall mean those persons designated as ethnicminority by the U.S. Bureau of Census. This information will be kept confidential.
HOME E-MAIL ADDRESS TNEMYAPDNAEPYTPIHSREBMEM
NOITCUDEDLLORYAPYBEGDELPDNUFAENDNAECAP-AESPSUOUNITNOC
PSEA-PACE for State Elections( ) PLEASE CHECK
NEA Fund for Federal Elections( ) PLEASE CHECK
A.) $52 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
A.) $15 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
)TNUOMARETNE()TNUOMARETNE(
I UNDERSTAND THAT OF THE TOTAL PSEA DUES, $4.50 IS FOR A ONE YEAR SUBSCRIPTION TO THE VOICE, AND OF THE TOTAL NEA DUES $5.65 IS FOR A ONE YEAR SUB-SCRIPTION TO NEA TODAY.
BY SIGNING THIS MEMBERSHIP FORM, I AM ENROLLING FOR THE 2010-2011 MEMBERSHIP YEAR AND ALSO AGREEING TO MAINTAIN MY MEMBERSHIP IN THE APPROPRIATECATEGORY EACH MEMBERSHIP YEAR THEREAFTER. I MAY REVOKE MY MEMBERSHIP BY NOTIFYING, IN WRITING, MY LOCAL ASSOCIATION, WHEN AVAILABLE, OR PSEANO LATER THAN OCTOBER 1 OF THAT MEMBERSHIP YEAR.
DUES PAYMENTS AND CONTRIBUTIONS TO NEA FUND AND PSEA-PACE, IF APPLICABLE, ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL OR STATEINCOME TAX PURPOSES. DUES PAYMENTS OR A PORTION MAY BE DEDUCTIBLE AS A MISCELLANEOUS ITEMIZED DEDUCTION.
SIGNATURE
Local Officer Verification RequiredPLEASE INITIAL
PLEASE RETURN THE FIRST TWO COPIES OF THIS FORM TO PSEA
Pennsylvania is a unified state. The NEA, PSEA and local associations may not be joined separately.Dues cannot be pro-rated.( ) PLEASE CHECK ONEEA MEMBERSHIP
10 Active-Annual12 Active-1/2 Year13 Active- Less Than 500 Hours
21 ESP-Full Time23 ESP-School Year24 ESP-Greater than 2 hours; up to
and including 4 hours25 ESP- Up to and including 2 hours31 ESP-1/2 year Full-time33 ESP-1/2 year School year34 ESP-1/2 year Greater than 2
hours; up to and including 4 hours35 ESP-1/2 yr Up to and including 2 hrs
ESP MEMBERSHIP
SUBSTITUTE18 Substitute (day to day)
ASSOCIATE19 Associate (PSEA only)
PSEA DUES (from above):NEA DUES (from above):
ARBITRATION ASSESSMENT (from above):LOCAL DUES:PSEA-PACE CONTRIBUTION (from pledge):NEA FUND CONTRIBUTION (from pledge):TOTAL PAYMENT:
PSEAREGIONASSESSMENT TOTAL
427.00218.50114.25
213.50109.25
57.00
57.00109.25
57.0031.00
31.00
25.00
25.00
166.0088.0049.25
96.5096.5053.50
32.0053.5053.5032.00
32.00
15.00
593.00306.50163.50
318.50212.75114.40
92.90167.00114.00
64.95
64.95
40.00
25.00
5.504.502.50
2.502.752.251.25
1.25
ARBITRATIONASSESSMENT
3.002.501.40
1.401.501.250.70
0.70
$
$
ETAD/ETAD/
5/10
PDE ID#
500153
0.00
NEA
REGION ASSESSMENT (from above):
INTELLIPRINT SOLUTIONS, INC. HARRISBURG, PA 17111 P8173 CE 5/10
LOCAL Copy
537791
THE PENNSYLVANIA STATE EDUCATION ASSOCIATIONNATIONAL EDUCATION ASSOCIATION
2010 ENROLLMENT FORM 2011EMANGNIDLIUBREYOLPMELANOITACUDE/EMANNOITAICOSSALACOLREBMUNNOITAICOSSALACOL
SS# OR PSEA ID# TITLEMRS.MISSMS.
MR.DR.
LAITINIELDDIMEMANTSRIFEMANTSAL
STREET ADDRESS EDOCPIZETATSYTIC
01 Preschool02 Kindergarten
03 Elementary04 Middle Sch/Jr Hg
05 High School06 Community/Junior College/Two-Year Associate Degree
07 College08 University
09 OtherEMPLOYMENT LEVEL ( ) PLEASE CHECK ONE
EMPLOYMENT CODES: ( ) PLEASE CHECK ONE
101 Adult Ed102 Art103 Business Ed104 Coach105 Communications106 Computer Science107 Driver Ed108 English/
Language Arts109 Foreign Language
& Literature110 Health &
Physical Education111 Family &
Consumer Sciences112 Library Science113 Mathematics
Classroom Teacher114 Music115 Reading116 Science117 Social Studies118 Speech Therapist120 Technology Ed.121 General Subject122 No Subject123 Other124 Gifted125 Special Education126 Athletic Trainer127 English as
Second Language128 Literacy Coach129 Alternative Ed
Academic Areas201 Agriculture202 Business203 Distributive205 Family &
Consumer Sciences206 Technology Education207 Trade and Industrial208 Other/Votech209 Nursing Educator210 Physical Therapy
Educator211 Occupational
Therapy Educator
Career/Technical Studies301 Agriculture302 Architecture303 Biology304 Business305 Communications306 Computer Science307 Education308 Engineering309 English310 Foreign Languages311 Geography313 Family &
Consumer Sciences314 Law315 Library
Higher Ed316 Mathematics317 Military Science318 Philosophy319 Physical
Science320 Psychology321 Religion322 Social Science323 No Subject324 Other325 Nursing Educator326 Physical
Therapy Educator327 Occupational
Therapy Educator
401 Chief/AssistantAdministrator
402 Supervisor403 Other
Administration404 Principal405 Assistant
Principal
Administration/Supervision601 A-V Technician602 Custodian603 Maintenance
Personnel604 Food Service605 Secretarial/Clerical606 Aide
Non Instructional607 Bus Driver608 Confidential
Personnel610 Other611 Educational
Paraprofessional
ESP
501 Counselor502 Dental Hygienist503 H & S Visitor504 School Nurse505 School Psychologist506 Occupational Therapist507 Physical Therapist
Pupil Services
DATE OF BIRTH
GENDER SCHOOL DISTRICT CODEWHERE YOU LIVE (OVER)
POLITICAL AFFILIATION
AREA CODE HOME TELEPHONE NUMBER
FEMALEMALE
MO DAY YEARREPUBLICAN DEMOCRAT INDEPENDENT NONE
ETHNIC CLASSIFICATION
01 American Indian/Alaska Native02 Asian03 Black
04 Hispanic05 Caucasian06 Biracial
07 Multiethnic08 Native Hawaiian or other
Pacific Islander
PSEA is commited to assuring the equitable representation of members of ethnic minority groups at allgovernance levels of the Association. To help achieve this goal, completion of this section is stronglyencouraged. Failure to do so, however, will not affect your membership status, rights or benefits in NEA,PSEA, the local or any of their affiliates. Ethnic minority shall mean those persons designated as ethnicminority by the U.S. Bureau of Census. This information will be kept confidential.
HOME E-MAIL ADDRESS TNEMYAPDNAEPYTPIHSREBMEM
NOITCUDEDLLORYAPYBEGDELPDNUFAENDNAECAP-AESPSUOUNITNOC
PSEA-PACE for State Elections( ) PLEASE CHECK
NEA Fund for Federal Elections( ) PLEASE CHECK
A.) $52 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
A.) $15 CONTRIBUTION (SUGGESTED)B.) $ OTHER CONTRIBUTION
)TNUOMARETNE()TNUOMARETNE(
I UNDERSTAND THAT OF THE TOTAL PSEA DUES, $4.50 IS FOR A ONE YEAR SUBSCRIPTION TO THE VOICE, AND OF THE TOTAL NEA DUES $5.65 IS FOR A ONE YEAR SUB-SCRIPTION TO NEA TODAY.
BY SIGNING THIS MEMBERSHIP FORM, I AM ENROLLING FOR THE 2010-2011 MEMBERSHIP YEAR AND ALSO AGREEING TO MAINTAIN MY MEMBERSHIP IN THE APPROPRIATECATEGORY EACH MEMBERSHIP YEAR THEREAFTER. I MAY REVOKE MY MEMBERSHIP BY NOTIFYING, IN WRITING, MY LOCAL ASSOCIATION, WHEN AVAILABLE, OR PSEANO LATER THAN OCTOBER 1 OF THAT MEMBERSHIP YEAR.
DUES PAYMENTS AND CONTRIBUTIONS TO NEA FUND AND PSEA-PACE, IF APPLICABLE, ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS FOR FEDERAL OR STATEINCOME TAX PURPOSES. DUES PAYMENTS OR A PORTION MAY BE DEDUCTIBLE AS A MISCELLANEOUS ITEMIZED DEDUCTION.
SIGNATURE
Local Officer Verification RequiredPLEASE INITIAL
PLEASE RETURN THE FIRST TWO COPIES OF THIS FORM TO PSEA
Pennsylvania is a unified state. The NEA, PSEA and local associations may not be joined separately.Dues cannot be pro-rated.( ) PLEASE CHECK ONEEA MEMBERSHIP
10 Active-Annual12 Active-1/2 Year13 Active- Less Than 500 Hours
21 ESP-Full Time23 ESP-School Year24 ESP-Greater than 2 hours; up to
and including 4 hours25 ESP- Up to and including 2 hours31 ESP-1/2 year Full-time33 ESP-1/2 year School year34 ESP-1/2 year Greater than 2
hours; up to and including 4 hours35 ESP-1/2 yr Up to and including 2 hrs
ESP MEMBERSHIP
SUBSTITUTE18 Substitute (day to day)
ASSOCIATE19 Associate (PSEA only)
PSEA DUES (from above):NEA DUES (from above):
ARBITRATION ASSESSMENT (from above):LOCAL DUES:PSEA-PACE CONTRIBUTION (from pledge):NEA FUND CONTRIBUTION (from pledge):TOTAL PAYMENT:
PSEAREGIONASSESSMENT TOTAL
427.00218.50114.25
213.50109.25
57.00
57.00109.25
57.0031.00
31.00
25.00
25.00
166.0088.0049.25
96.5096.5053.50
32.0053.5053.5032.00
32.00
15.00
593.00306.50163.50
318.50212.75114.40
92.90167.00114.00
64.95
64.95
40.00
25.00
5.504.502.50
2.502.752.251.25
1.25
ARBITRATIONASSESSMENT
3.002.501.40
1.401.501.250.70
0.70
$
$
ETAD/ETAD/
5/10
PDE ID#
500153
0.00
NEA
REGION ASSESSMENT (from above):
INTELLIPRINT SOLUTIONS, INC. HARRISBURG, PA 17111 P8173 CE 5/10
MEMBER Copy
537791B
SCHOOLDISTRICT CODEADAMSBermudian Springs 01110Conewago Valley 01160Fairfield Area 01305Gettysburg Area 01375Littlestown Area 01520Upper Adams 01852
ALLEGHENYAllegheny Valley 02060Avonworth 02075Baldwin Whitehall 02110Bethel Park 02125Brentwood Boro 02145Carlynton 02160Chartiers Valley 02175Clairton City 02190Comall 02210Deer Lakes 02225Duquesne City 02250East Allegheny 02280Elizabeth Forward 02315Fort Cherry 63240Fox Chapel Area 02391Gateway 02410Hampton Township 02460Highlands 02475Keystone Oaks 02500Mckeesport Area 02600Montour 02630Moon Area 02634Mount Lebanon 02640North Allegheny 02685Northgate 02687North Hills 02690Penn Hills 02735Penn Trafford 65710Pine-Richland 02100Pittsburgh 02745Plum Borough 02750Quaker Valley 02775Riverview 02820Shaler Area 02830South Allegheny 02865South Fayette Twp. 02870South Park 02875Steel Valley 02883Sto Rox 02885Upper St. Clair Twp. 02920West Allegheny 02940West Jefferson Hills 02955West Mifflin Area 02960Wilkinsburg Boro 02980Woodland Hills 02990
ARMSTRONGAlly Clarion Valley 16030Apollo Ridge 03060Armstrong 03085Freeport Area 03305Karns City Area 10360Kiski Area 65440Leechburg Area 03450Redbank Valley 16800
BEAVERAliquippa Boro 04050Ambridge Area 04070Beaver Area 04120Big Beaver Falls 04150Blackhawk 04160Central Valley 04200Ellwood City Area 37200Freedom Area 04285Hopewell Area 04410Midland Boro 04530New Brighton Area 04565Riverside Beaver Co. 04585Rochester Area 04690Southside Area 04740Western Beaver 04930
BEDFORDBedford Area 05100Chestnut Ridge 05150Claysburg Kimmel 07150Everett Area 05300Northern Bedford Co. 05600Tussey Mountain 05800
BERKSAntietam 06050Boyertown Area 06075Brandywine Hts. Area 06085Conrad Weiser Area 06110Daniel Boone Area 06150Exeter Township 06200Fleetwood Area 06250Governor Mifflin 06300Hamburg Area 06350Kutztown Area 06400Muhlenburg Twp. 06550Oley Valley 06650Reading 06700Schuylkill Valley 06750Tulpehocken Area 06800Twin Valley 06810Upper Perkiomen 46860
01960nosliWWyomissing 06935
BLAIRAltoona Area 07050Bellwood Area 07100Claysburg Kimmel 07150Holidaysburg 07350Spring Cove 07750Tyrone Area 07800Williamsburg Comm 07900
SCHOOLDISTRICT CODEBRADFORDAthens Area 08050Canton Area 08100No. East Bradford 08300Sayre Area 08600Towanda Area 08650Troy Area 08665Wyalusing Area 08900
SCHOOLDISTRICT CODECOLUMBIABenton Area 19100Berwick Area 19110Bloomsburg Area 19120Central Columbia 19150Millville Area 19500Mt. Carmel Area 49510North Schuylkill 54500South Columbia Area 19750
SCHOOLDISTRICT CODEHUNTINGDONHuntingdon Area 31250Juniata Valley 31280Mount Union Area 31600So. Huntingdon Co. 31750Tussey Mountain 05800Tyrone Area 07800
SCHOOLDISTRICT CODEMC KEANBradford 42080Kane Area 42230Oswayo Valley 53750Otto Eldred 42600Port Allegany 42630Smethport Area 42750
SCHOOLDISTRICT CODESOMERSETBerlin Brothersvalley 56100Conemaugh Twp. Area 56180Meyersdale Area 56520North Star 56550Rockwood Area 56630Salisbury Elk Lick 56700Shade Central City 56720Shanksville Styncrk 56740Somerset Area 56770Turkeyfoot-Vlly Area 56840Windber Area 56910
BUCKSBensalem Township 09100Bristol Boro 09130Bristol Township 09135Centennial 09200Central Bucks 09210Council Rock 09235Easton Area 48330Morrisville Boro 09720Neshaminy 09750New Hope Solebury 09760North Penn 46570Palisades 09800Pennridge 09810Pennsbury 09820Quakertown Comm. 09840Souderton Area 46710
BUTLERAlly Clarion Valley 16030Butler Area 10125Freeport Area 03305Karns City Area 10360Mars Area 10500Moniteau 10535Seneca Valley 10790Slippery Rock Area 10750South Butler 10780
CAMBRIABlacklick Valley 11060Cambria Heights 11120Central Cambria 11130Conemaugh Valley 11140Ferndale Area 11200Forest Hills 11220Glendale 17300Greater Johnstown 11250Northern Cambria 11450Penn Cambria 11600Portage Area 11630Richland 11650Westmont Hilltop 11850Windber Area 56910
CAMERONCameron Co. 12270
CARBONHazelton Area 40330Jim Thorpe Area 13500Lehighton Area 13550Palmerton Area 13650Panther Valley 13660Weatherly Area 13900
CENTREBald Eagle Area 14100Bellefonte Area 14110Keystone Central 18360Penns Valley 14700Philipsburg Osceola 17700State College Area 14800Tyrone Area 07800
CHESTERAvon Grove 15050Coatesville Area 15190Downington Area 15200Great Valley 15350Kennett Cons 15400Octorara Area 15650Owen J. Roberts 15660Oxford Area 15670Phoenixville Area 15720Spring Ford Area 46730Tredyffrin Easttown 15780Twin Valley 06810Unionville Chadds Fd. 15850West Chester Area 15900
CLARIONAlly Clarion Valley 16030Armstrong 03085Clarion Area 16120Clarion-Limestone Area 16170Keystone 16650North Clarion County 16750Redbank Valley 16800
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CLEARFIELDClearfield Area 17100Curwensville Area 17180Dubois Area 17200Glendale 17300Harmony 17350Moshannon Valley 17500Philipsburg Osceola 17700Purchase Line 32730West Branch Area 17900
CLINTONJersey Shore Area 41400Keystone Central 18360West Branch Area 17900
CRAWFORDConneaut 20103Corry Area 25145Crawford Central 20135Jamestown Area 43360Penncrest 20470Titusville Area 61720Union City Area 25910
CUMBERLANDBig Spring 21050Camp Hill 21100Carlisle Area 21110Cumberland Valley 21160East Pennsboro Area 21250Mechanicsburg Area 21650Shippensburg Area 21800South Middleton 21830West Shore 21900
DAUPHINCentral Dauphin 22140Derry Twp. 22175Halifax Area 22250Harrisburg City 22275Lower Dauphin 22400Middletown Area 22600Millersburg Area 22610Steelton Highspire 22800Susquehanna Twp. 22830Susquenita 50600Upper Dauphin Area 22900Williams Valley 54880
DELAWAREChester Upland 23123Chichester 23130Garnet Valley 23410Haverford Township 23450Interboro 23510Marple Newtown 23550Penn Delco 23690Radnor Township 23760
07732yeldiRRose Tree Media 23790Southeast Delco 23840Springfield 23850Unionville-Chadds Fd. 15850Upper Darby 23945Wallingford Swarthmr 23960West Chester Area 15900William Penn 23965
ELKBrockway Area 33070Forest Area 27200Johnsonburg Area 24350Kane Area 42230Ridgway Area 24600St. Marys Area 24800
ERIECorry Area 25145Erie City 25260Fairview 25330Fort Leboeuf 25355General McLane 25390
50452drariGHarbor Creek 25435Iroquois 25655Millcreek Township 25760North East 25830Northwestern 25850Union City Area 25910Wattsburg Area 25970
FAYETTEAlbert Gallatin 26030Belle Vernon Area 65060Brownsville Area 26080Connellsville 26130Frazier 26290Laurel Highlands 26400Southmoreland 65750Uniontown Area 26800
FORESTForest Area 27200
FRANKLINChambersburg Area 28130Fannett Metal 28200Greencastle Antrim 28300Shippensburg Area 21800Tuscarora 28600Waynesboro Area 28900
FULTONCentral Fulton 29130Forbes Road 29230Southern Fulton 29750
GREENECarmichaels Area 30130Central Greene 30140Jefferson Morgan 30350So. Eastern Greene 30650West Greene 30850
INDIANAApollo Ridge 03060Armstrong 03085Blairsville-Saltsbg 32110Harmony 17350Homer Center 32330Indiana Area 32370Marion Center Area 32520Penns Manor Area 32630Punxsutawney Area 33800Purchase Line 32730
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JEFFERSONBrockway Area 33070Brookville Area 33080Clarion-Limestone Area 16170Dubois Area 17200Punxsutawney Area 33800
JUNIATAGreenwood 50300Juniata County 34360
LACKAWANNAAbington Heights 35030Carbondale Area 35130Dunmore 35220Forest City Region 58300Lackawanna Trail 66500Lakeland 35460Mid Valley 35550North Pocono 35650Old Forge 35660Riverside 35700Scranton City 35740Valley View 35840
LANCASTERCocalico 36130Columbia Boro 36150Conestoga Valley 36170Donegal 36220Eastern Lancaster 36230Elizabethtown Area 36240Ephrata Area 36260Hempfield 36310Lampeter Strasbg 36360Lancaster 36400Manheim Central 36440Manheim Township 36450Octorara Area 15650Penn Manor 36520Pequea Valley 36530Solanco 36700Warwick 36900
LAWRENCEBlackhawk 04160Ellwood City Area 37200
00473leruaLMohawk Area 37500Neshannock Township 37520New Castle Area 37530Shenango Area 37620Union Area 37700Wilmington Area 37800
LEBANONAnnville Cleona 38030Cornwall Lebanon 38130Eastern Lebanon Co. 38230Lebanon 38460Northern Lebanon 38500Palmyra Area 38530
LEHIGHAllentown City 39030Bethlehem Area 48100Catasauqua Area 39130East Penn 39230Northern Lehigh 39450North Western Lehigh 39460Parkland 39510Salisbury Twp. 39560Southern Lehigh 39570Whitehall Coplay 39780
LUZERNEBerwick Area 19110Crestwood 40140
06104sallaDGreater Nanicoke Ar. 40260Hanover Area 40300Hazleton Area 40330Lake-Lehman 40390Northwest Area 40600Pittston Area 40660Wilkes-Barre Area 40885Wyoming Area 40920Wyoming Valy. West 40930
LYCOMINGCanton Area 08100East Lycoming 41200Jersey Shore Area 41400Loyalsock Twp. 41420Montgomery Area 41500Montoursville Area 41510
03514ycnuMSo. Williamsport 41610Southern Troga 59700Wellsboro Area 59850Williamsport Area 41720
MERCERCommodore Perry 43130Crawford Central 20135Farrell Area 43250Greenville Area 43280Grove City Area 43290Hermitage 43330Jamestown Area 43360Lakeview 43390Mercer Area 43500Reynolds 43530Sharon City 43560Sharpsville Area 43570West Middlesex Area 43750Wilmington Area 37800
MIFFLINMifflin County 44460Mount Union Area 31600
MONROEEast Strousbg Area 45200Pleasant Valley 45520Pocono Mountain 45540Stoudsburg Area 45600
MONTGOMERYAbington 46030Boyertown Area 06075Bryn Athyn Boro 46050Chelteham 46130Colonial 46160Hatboro Horsham 46360Jenkintown 46380Lower Marion 46450Lower Moreland Twp. 46460Methacon 46530Norristown Area 46560North Penn 46570Perkiomen Valley 46610Pottsgrove 46630Pottstown 46640Souderton Area 46710Springfield Twp. 46720Spring Ford Area 46730Upper Dublin 46830Upper Merion Area 46840U. Moreland Twp. 46850Upper Perkiomen 46860Wissahickon 46930
MONTOURDanville Area 47180Warrior Run 49800
NORTHAMPTONBangor Area 48080Bethlehem Area 48100Catasaugua 39130Easton Area 48330Nazareth Area 48480Northampton Area 48490Northern Lehigh 39450Pen Argyl Area 48560Saucon Valley 48600Wilson Area 48860
NORTHUMBERLANDDanville Area 47180Line Mountain 49350Milton Area 49500Mt. Carmel Area 49510Shamokin Area 49650Shikellamy 49660S. Columbia Area 19750Warrior Run 49800
PERRYFannett Metal 28200Greenwood 50300Newport 50400Susquenita 50600West Perry 50800
PHILADELPHIAPhiladelphia City 51500
PIKEDelaware Valley 52200E. Stroudsburg Area 45200Wallenpaupack 64830
POTTERAustin Area 53030Coudersport Area 53130Galeton Area 53280Keystone Central 18360Northern Potter 53550Oswayo Valley 53750Port Allegany 42630
SCHUYLKILLBlue Mountain 54080Hazelton Area 40330Mahanoy Area 54450Minersville Area 54470North Schuylkill 54500Panther Valley 13660Pine Grove Area 54600Pottsville Area 54610Saint Clair Area 54680Shenandoah Valley 54720Schuylkill Haven 54730Tamaqua Area 54760Tri Valley 54780Williams Valley 54880
SNYDERMidd-West 55500Selinsgrove 55710
SULLIVANSullivan Co. 57630
SUSQUEHANNABlue Ridge 58100Elk Lake 58250Forest City Regional 58300Montrose Area 58450Mountain View 58460Susquehanna Comm. 58650
TIOGACanton Area 08100Galeton Area 53280Northern Tioga 59600Southern Tioga 59700Wellsboro Area 59850
UNIONLewisburg Area 60400Mifflinburg Area 60500Milton Area 49500Warrior Run 49800
VENANGOAlly Clarion Vlly 16030Cranberry Area 61130Forest Area 27200Franklin Area 61220Oil City Area 61620Penncrest 20470Titusville Area 61720Valley Grove 61860
WARRENCorry Area 25145Titusville Area 61720Warren County 62830
WASHINGTONAvella Area 63050Bentworth 63090Bethlehem Center 63100Brownsville Area 26080Burgettstown Area 63120California Area 63150Canon McMillan 63170Charleroi 63180Chartiers Houston 63190Fort Cherry 63240McGuffey 63390Peters Township 63650Ringgold 63700Trinity Area 63800Washington 63880
WAYNEForest City Region 58300North Pocono 35650Susquehanna Comm. 58650Wallenpaupack 64830Wayne Highlands 64870Western Wayne 64890
WESTMORELANDBelle Vernon Area 65060Blairsville-Saltsubrg 32110
07056llerruBDerry Area 65160Franklin Regional 65260Greater Latrobe 65310Greensburg Salem 65320Hempfield Area 65380Jeannette City 65410Kiski Area 65440Leechburg Area 03450Ligonier Valley 65490Monessen City 65580Mt. Pleasant Area 65590New Kensngtn Arnid. 65630Norwin 65650Penn Trafford 65710Southmoreland 65750
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WYOMINGElk-Lake 58250Lackawanna Trail 66500Lake-Lehman 40390Tunkhannock Area 66750Wyalusing Area 08900Wyoming Area 40920
YORKCentral York 67130Dallastown Area 67160Dover Area 67180Eastern York 67220Hanover Public 67280Northeastern York 67440Northern York County 67460Red Lion Area 67550South Eastern 67620South Western 67640Southern York 67650Spring Grove Area 67670West Shore 21900West York Area 67850York City 67900York Suburban 67940
PENNSYLVANIA SCHOOL DISTRICTS AND CODES BY COUNTY
