Piedmont UniServ Membership Application 2022-2023

Completing this application ensures your membership in your Local Education Association, the Virginia Education Association, and the National Education Association.

NOTE: THIS FORM MAY ONLY BE USED IF YOU ARE ELECTING PAYROLL DEDUCTION AS YOUR PAY METHOD.
PLEASE CLICK HERE TO PAY BY CREDIT CARD OR EFT.

Name Name * First Middle Last
Employee ID *
Local Association (School Division) *
Select Work Location (Charlotte): *
Select Work Location (Danville): *
Select Work Location (Halifax): *
Select Work Location (Henry): *
Select Work Location (Martinsville): *
Select Work Location (Patrick): *
Select Work Location (Pittsylvania): *
Position *
Subject *
Personal Information

Your personal information is safe and confidential. We safeguard it and share only with VEA member benefits partners.
Birth Date Birth Date * / MM / DD YYYY
Social Security (last 4) # *
Maximum of 4 characters allowed. Currently Entered: 0 characters.
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Personal / Non-work Email *

Confirm Email Address *
Work Email

Confirm Email Address
Primary Phone Primary Phone * - ### - ### ####
Primary Phone Type *

Primary Phone Type Home Cell Work
Secondary Phone Secondary Phone - ### - ### ####
Secondary Phone Type

Secondary Phone Type Home Cell Work
Telephone Consumer Protection Act. By providing my phone number, I understand that the National Education Association and its affiliates, including the Virginia Education Association, the local Association, NEA Member Benefits, and NEA360, may use automated calling techniques and/or text message me on my cellular phone on a periodic basis. The National Education Association, the Virginia Education Association, and the local Association will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.
Check all that apply:

Check all that apply: I am a first year educator I have 5 years experience or less I was an SVEA Aspiring Educator Member last year I was a VEA/NEA Member last year
Gender *

Gender Female Male Non-Binary Transgender Female Transgender Male Gender Expansive/Non-Conforming
Ethnicity

Ethnic Minority information is optional and not providing it will in no way effect your membership status, rights, or benefits in NEA, VEA, or any of their affiliates. If included, this information will be kept confidential and will be used to determine the proportion of ethnic minority delegates in state and national delegations.

Ethnicity

Ethnic Minority information is optional and not providing it will in no way effect your membership status, rights, or benefits in NEA, VEA, or any of their affiliates. If included, this information will be kept confidential and will be used to determine the proportion of ethnic minority delegates in state and national delegations.
American Indian/Alaskan Native Asian Black Caucasian Hispanic Multi-Ethnic Native Hawaiian/Pacific Islander Other Other
Dues Classification

Dues payments are not deductible as a charitable contribution, however they may be deductible as a miscellaneous itemized expense. Consult your tax advisor for details.
Please select your status (Charlotte): *

Please select your status (Charlotte): Professional Full Time $55.64 per pay period Professional Half Time $28.86 per pay period Education Support Professional Full Time $29.68 per pay period Education Support Professional Half Time $16.14 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Danville): *

Please select your status (Danville): Professional Full Time $60.30 per pay period Professional Half Time $31.30 per pay period Education Support Professional Full Time $32.20 per pay period Education Support Professional Half Time $17.53 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Halifax): *

Please select your status (Halifax): Professional Full Time $61.60 per pay period Professional Half Time $31.95 per pay period Education Support Professional Full Time $32.85 per pay period Education Support Professional Half Time $17.85 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Henry): *

Please select your status (Henry): Professional Full Time $51.92 per pay period Professional Half Time $26.92 per pay period Education Support Professional Full Time $27.67 per pay period Education Support Professional Half Time $15.02 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Martinsville): *

Please select your status (Martinsville): Professional Full Time $51.75 per pay period Professional Half Time $26.83 per pay period Education Support Professional Full Time $27.58 per pay period Education Support Professional Half Time $14.98 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Patrick): *

Please select your status (Patrick): Professional Full Time $54.91 per pay period Professional Half Time $28.55 per pay period Education Support Professional Full Time $29.36 per pay period Education Support Professional Half Time $15.98 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Please select your status (Pittsylvania): *

Please select your status (Pittsylvania): Professional Full Time $61.30 per pay period Professional Half Time $31.80 per pay period Education Support Professional Full Time $32.70 per pay period Education Support Professional Half Time $17.78 per pay period Professional Substitute $164.75 per year (Credit Card or Check Only)
Pay Method *

Pay Method Payroll Deduction
Signature (Credit Card / EFT)

I authorize the Virginia Education Association to accept the checked payment in the amount indicated above.

Annual membership dues to the NEA include $5.65 for NEA Today, $3.40 for NEA-Retired and/or $6.58 for the Higher Education publications. The NEA publication(s) received by members are based on membership category. Annual membership dues to VEA include a subscription to the Virginia Journal of Education.

Membership is open only to those who agree to subscribe to the principles, goals and objectives of the Association and to abide by its charter, constitution and bylaws.
Signature (Payroll Deduction)

Annual membership dues to the NEA include $5.65 for NEA Today, $3.40 for NEA-Retired and/or $6.58 for the Higher Education publications. The NEA publication(s) received by members are based on membership category. Annual membership dues to VEA include a subscription to the Virginia Journal of Education.

Membership is open only to those who agree to subscribe to the principles, goals and objectives of the Association and to abide by its charter, constitution and bylaws.

I authorize payroll deduction of Association dues by my employer unless I revoke this authorization in writing to the Local Association and School Board.
Sign by drawing or typing your signature in the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Who encouraged you to join?
UniServ Phone Number
UniServ Email Address

Piedmont UniServ Membership Application 2022-2023

Piedmont UniServ Membership Application 2022-2023

Personal Information

Dues Classification

Signature (Credit Card / EFT)

Signature (Payroll Deduction)