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NEA-Dallas / TSTA / NEA

National Education Association - Dallas


Texas State Teachers Association / National Education Association
Please return this completed & signed form to: NEA-Dallas Membership Division at 6500 Greenville Ave., Suite 520, Dallas, TX 75206, or School Mailbox #118.
For questions: (214) 821-2061 neadallas@logixonline.com www.neadallas.com
2019 - 2020 ENROLLMENT APPLICATION
Last Name Social Security Number Dallas ISD Employee Number

First Name Date of Birth Hire Date

Address Campus/Work Location

City State Zip Position Department

Ethnity / Gender
Personal Email
o American Indian/Alaska Native o Native Hawaiian/Pacific Islndr.
o Black/African American o Unknown
Work Email
o Hispanic o Multi-Ethnic
o Home o Cell o Other ______________ o Caucasian (not of Spanish Origin) o Other
Phone Number
o Asian
o Home o Cell o Other ____________ GENDER: o Male o Female
Alternate Phone Number Gener information is optional and failure to provide it will in no way affect your membership status, rights, or benefits in NEA, TSTA, or
any of their affiliates. This information will be kept confidential.

1st year to profession? o Yes o No o Contribute to TSTA-PAC $_________.______ _____ Initial to Opt-Out
(See disclaimer below & on back)

The TSTA Political Action Committee (TSTA-PAC) and the NEA Fund for Children and Public Education (NEA Fund) collect voluntary contributions from Association members which are used for political purposes, including, but not limited to, making contributions to and expenditures on behalf of pro-public education candidates for office. Contributions are
voluntary; making a contribution is neither a condition of employment nor membership in the Association, and members have the right to refuse to contribute without suffering any reprisal. Only Association members, staff and their immediate families who are U.S. citizens or lawful permanent residents may contribute.
Contributions are not deductible as charitable contributions for federal income tax purposes.
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and name of employer for each individual whose contributions aggregate in excess of $200 in a calendar year.
“I decline to contribute to TSTA-PAC and I understand this will not in any way affect my membership status or rights.”
Membership is open only to those who agree to subscribe to the goals and objectives of the Association and to abide by its constitution and bylaws.
Dues payments are not deductible as charitable contributions for federal income tax purposes. Dues payments (or a portion) may be deductible as a miscellaneous itemized deduction.
Legal Liability Coverage: Members of TSTA/NEA are automatically covered by $1,000,000 of professional liability insurance ($300,000 for civil rights claims) while acting within the scope of their educational employment. This coverage is underwritten by the Nautilus Insurance Company, or successor provider selected by NEA. Coverage is subject to the
terms, conditions and exclusions of the policy which is available to members upon request by calling the TSTA Help Center at 877-ASK-TSTA. These insurers may not be subject to all the laws and regulations of Texas. The insurance solvency guarantee fund may not be available to you or to TSTA.
Employment Defense: In general, in order to be considered for legal services for job protection, membership is required for at least 30 days before the member knew or should have known of the events or occurrences leading up to the action complained about. Pre-existing conditions will not be pursued, except by the discretion of TSTA.

o Please check here if you would like to receive TSTA's electronic newsletter, the TSTA Briefing, and to which email would you like for it to be emailed to
you at least once a week? o Personal Email o Work Email

Choose One: Method of Payment Options


o Option 1: Automatic Bank Draft / EFT Card Type:_________________ Card Number:_______________________ Expiration Date:________________
o Option 2: Recurring Credit Card
By checking this box, I authorize TSTA to begin monthly deductions from my bank account or credit card. Monthly deductions run from September - July. The authorization will remain
in effect until revoked by me in writing at least 10 business days before the next deduction. If any increase in amount will occur, I will receive at least a 10 calendar day notice..
>>>> A BLANK check marked VOID must be attached. <<<<

SSN: For Dallas ISD Payroll Use Only


ID No. PPs: Dues Code:
Dues Ded: TL: Start Date:
Wrk hrs Part Time / Full Time

o Option 3: Payroll Deduction o Monthly o Biweekly


I hereby authorize the Dallas ISD payroll department to deduct the above amount in the indicated number of equal payments in order to pay my dues to NEA-Dallas and for political
action contributors indicated. The authorization will continue for this school year and future years, including any increase that may occur, until I give written notice or sign a
cancellation form and submit to NEA-Dallas to revoke. I further authorize any unpaid annual balance to be deducted from my final check.

Member Signature Printed Name Date


*All changes should go through NEA-Dallas, not directly through the district payroll department.
TSTA-PAC Disclaimer: The TSTA Political Action Committee (TSTA-PAC) and the National Education Association Fund for Children and
Public Education collect voluntary contributions from Association members and use these contributions for political purposes.,
including, but not limited to, making contributions to and expenditures on behalf of friends of public education who are candidates for
federal office. Only U.S. citizens or lawful permanent residents may contribute to the NEA Fund. Contributions to the NEA Fund are
voluntary; making a contribution is neither a condition of employment nor membership in the Association, and members have the right
to refuse to contribute without suffering any reprisal. Although the NEA Fund for Children and Public Education requests an annual
contribution of $15, this is only a suggestion. A member may contribute more or less than the suggested amount, or may contribute
nothing at all, without it affecting his or her membership status, rights, or benefits in NEA or any of its affiliates. Contributions or gifts
to the NEA Fund for Children and Public Education, TSTA-PAC and local PACs are not deductible as charitable contributions for federal
income tax purposes. Federal law requires political committees to report the name, mailing address, occupation, and name of employer
for each individual whose contributions aggregate in excess of $200 in a calendar year. Federal law prohibits the NEA Fund for Children
and Public Education from receiving donations from persons other than members of NEA and its affiliates, and their immediate families.
All donations from persons other than members of NEA and its affiliates, and their immediate families, will be returned forthwith. If I
decline to contribute to TSTA-PAC, I understand this will not in any way affect my membership status or rights. Membership is open
only to those who agree to subscribe to the goals and objectives of the Association and to abide by its constitution and bylaws.