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 * I HAVE READ AND AGREE TO WHAT IS STATED IN THE DISCLAIMER. Name * Please enter full name. Date * Please enter today's date. Home Address * Please enter your home address. City * Please enter the city of your home address Zip Code * Please enter the zip code of your home address. Phone Number * Please enter your phone number. School * Please enter what school/location you currently work at. Employee Number * Please enter your employee number. Personal Email Address * Please enter your personal email address. Birmingham American Federation of Teachers Monthly Dues Certified Personnel: $41.00 Uncertified Personnel:$21.00 Substitutes: $11.00 Position * Certified Personnel Uncertified Personnel Substitiute Please enter how your job position is categorized. Job Title * Please enter your current job title. 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 * Enter your social security number. Policy and Policyholdyer Local Union Number: 2115 Policyholder: American Federation of Teachers Policy Number: C- 4363 Name of Beneficiary * Please enter the name of your beneficiary. Address * Please enter the address of the beneficiary. City * Please enter the city of the beneficiary. State * Please enter the state of beneficiary. Zip Code of Beneficiary * Please enter the zip code of beneficiary. 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. Leave this field blank