This application is payroll deduction only. For additional methods of payment connect with your UniServ Office. SOCIAL SECURITY NUMBER- (XXX-XX-_ _ _ _) LAST 4 DIGITS ONLY * Single Line Text DISTRICT EMPLOYEE NUMBER PREFERRED NAME/ NICKNAME LEGAL NAME (FIRST, MIDDLE, LAST) * RACE (optional)
**Race and Ethnicity – Race information is optional and failure to provide it will in no way affect your membership status, rights or benefits in NEA, UEA or any of their affiliates. This information will be kept confidential.
NON-WORK EMAIL (PREFERRED) * WORK EMAIL * CURRENT SCHOOL/WORK LOCATION SUBJECT TAUGHT POSITION (major assignment) LOCAL ASSOCIATION (SCHOOL DISTRICT) * MEMBERSHIP COMMITMENT * YES to Membership Commitment – I want to join with my fellow employees and become a member of the local association, the Utah Education 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 three associations. I hereby designate and empower the local association as my exclusive bargaining agent. PAYMENT AUTHORIZATION * YES to annual Payment Authorization – I hereby agree to pay the annual dues, fees, and assessments established by the three associations in consideration for the services the union provides. I understand that those annual amounts, due on September 1 are subject to periodic change by the governing bodies of the associations but may not exceed three percent (3%) of my monthly salary. I authorize on a continuing basis, and regardless of my membership status, the payment of those annual amounts established by the three associations through payroll deduction or other arrangements unless I revoke this authorization in a signed writing sent to the local association for which the authorization is set to be cancelled.
The District is hereby authorized and directed to deduct the specific sum certified by UEA or its designee, and to pay the dues to UEA or its designee by payroll deduction. I may revoke this dues deduction authorization by submitting a written directive to the District. 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. PAYROLL DEDUCTION (initial) * SIGNATURE (FULL NAME) *
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.