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Disclaimer
Please complete this survey to register for the Birmingham American Federation of Teachers. BY COMPLETING THIS FORM YOU AGREE TO THE FOLLOWING: AUTHORIZATION AND REQUEST THAT THE APPLICABLE MONTHLY DUES LISTED BELOW BE DEDUCTED FROM REGISTRANT’S SALARY EACH PAY DAY, AND FORWARD THE SAME TO THE BIRMINGHAM AMERICAN FEDERATION OF TEACHERS, LOCAL 2115, AS MONTHLY DUES TO SAID ORGANIZATION. THE REGISTRANT UNDERSTANDS THAT PAYROLL DEDUCTIONS ARE THE OPTION OF THE EMPLOYEE, THEREFORE ANNUAL NOTIFICATION OF THE PAYROLL OPTION IS HEREBY WAIVED. THE AUTHORIZATION SHALL REMAIN IN EFFECT UNTIL REVOKED BY REGISTRANT THROUGH A WRITTEN NOTICE ADDRESSED TO YOUR LOCAL DEPARTMENT AND A COPY TO LOCAL 2115.
Disclaimer Agreement
Name
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Date
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Home Address
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City
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Zip Code
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Phone Number
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School
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Employee Number
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Personal Email Address
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Birmingham American Federation of Teachers Monthly Dues
Certified Personnel: $41.00 Uncertified Personnel:$21.00 Substitutes: $11.00
Position
Certified Personnel
Uncertified Personnel
Substitiute
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Job Title
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Designation of Beneficiary for Accidental Death and Dismemberment Policy
This section is for the Designation of Beneficiary for Accidental Death and Dismemberment Policy.
Social Security Number
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Policy and Policyholdyer
Local Union Number: 2115 Policyholder: American Federation of Teachers Policy Number: C- 4363
Name of Beneficiary
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Address
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City
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State
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Zip Code of Beneficiary
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BEA/AEA Drop Form
NOTE: THIS FORM IS APPLICABLE TO THOSE WHO ARE CURRENTLY MEMBERS OF BEA/AEA. If not applicable put N/A
Cancellation Acknowledgement
Ms. Valerie Bishop, Please accept this letter as authorization to immediately cancel my membership with the BEA/AEA. Please respect my legal right to freely join or not join the organization of my choice without fear of harassment, intimidation, or interference. If not applicable enter N/A. If applicable enter your name.
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