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First Name
required
Last Name
required
Last 4 digits of Social Security
required
Date of Birth
required
Use MM/DD/YYYY format.
Address
required
City
required
State
required
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Conneticut
DC - Washington, D.C.
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
AS - American Samoa
GU - Guam
MP - Northern Mariana Islands
PR - Puerto Rico
VI - Virgin Islands
FM - Federated States of Micronesia
MH - Marshall Islands
PW - Palau
AA - America
AE - Europe
AP - Pacific
Zip Code
required
Home Phone Number
Cell Phone Number
Home Email Address
required
School Site
required
Subject / Grade Taught
required
Recruited By
required
Dues Deduction Authorization
I hereby agree to pay, and authorize my employer to deduct, the dues and assessments certified by MCEA to the School Board for each year hereafter from my salary, and direct and authorize my employer to pay such amounts to MCEA in accordance with payroll deduction procedures in effect; provided, however, I may cancel my membership and this authorization by providing thirty (30) days’ written notice to the School Board and MCEA, notifying them of such revocation, as provided by law. I understand my membership will not be cancelled until both parties have been duly notified in writing, and that a request to cancel submitted less than thirty (30) days before the end of any school year will be processed effective with the beginning of the subsequent school year.
Electronic Signature (Type Full Name)
required
By typing your name into this block, you are agreeing to the terms stated in the text above.
Date
required
Use MM/DD/YYYY format.
Martin County Employee ID No.
required
Verification
required
Location
Name
Address
Phone
Martin County Education Association
668 SE Monterey Road
Stuart, FL 34994
772-283-3727
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