2018-19 ATPE MEMBERSHIP APPLICATION MM
STEP 1
Method of Payment (select one)
atpe.org | (800) 777-ATPE
Payroll deduction— Complete this application form, including step 4
All other forms of payment–JOIN ONLINE
(not accepted after January 31, 2019)
Including credit card payment, credit card installments, and ACH bank draft
Personal check—Complete application form and attach personal check STEP 2
Personal Information
Name (first, middle, last)
Last 4 digits of SSN
ATPE member ID (optional)
Male
Birthdate (MM/DD/YY)
ISD
Campus
Cell phone (required)
Home phone (optional)
Personal email (required)
Position (optional)
Campus email (optional)
Employee ID number
Mailing address State
City ZIP
Recruited by I understand that ATPE may contact me via the information provided on this application form, including email and text, to communicate with me about my benefits and to administer my account.
I am interested in becoming an ATPE volunteer. STEP 3
Female
Membership Category (select one) & Invest in Education
Student Teacher, College Student, and Public members may join online at atpe.org. 2018-19 Professional, Associate, and Administrator memberships will not be accepted after Jan. 31, 2019. First-Time Professional memberships will not be accepted after Oct. 31, 2018.
Professional (teacher, counselor, etc.). . . . . . . . . . . . . . . . . . . . . . . . . $175 First-Time Professional (never been a professional member). . . . . . . . . $110 Associate (para-educator, aide, support staff, etc.). . . . . . . . . . . . . . . . . . $90 Administrator (principal, superintendent, etc.). . . . . . . . . . . . . . . . . . . $225
How to Submit Your Application Mail the application to: ATPE 305 E. Huntland Dr., Ste. 300 Austin, TX 78752 Or hand deliver it to an authorized ATPE representative. Faxed or scanned applications are not accepted.
Retired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10 DESIGNATED ATPE REPS
OPTIONAL: Invest in Education ATPE Local Unit Dues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Received Date
Support ATPE in your local school district.
Political Action Committee. . . . . . . . . . . . . . . . . . . . . . . . . $ Support legislative advocacy for educators and students.
12
Print Name Signature
TOTAL $
The ATPE membership year begins 8/1/18 and ends 7/31/19. Some benefits effective dates may not match effective membership dates. Visit atpe.org for disclosure details and limitations.
STEP 4
Payroll Deduction Authorization
2018–19 Professional, Associate, and Administrator memberships will not be accepted after Jan. 31, 2019. First-Time Professional memberships will not be accepted after Oct. 31, 2018. I authorize ISD to deduct membership dues and donations. I further authorize ATPE to notify the ISD of changes in the amount of my annual dues and the ISD to deduct the new amounts. If my employment with the ISD ends, I authorize any unpaid balance to be deducted from my final check. This authorization for deductions is effective until I give notice to the ISD that I want to revoke it.
Total Amount $
Last 4 digits of SSN
Total # of Deductions Date
I wish to cancel deduction of membership dues for: TX AFT
TCTA
TSTA
UEA
Other
Printed Name Signature
Employee ID