Mountain View UniServ Membership Application

Name Name * First Middle Last
Employee ID *
Local Association (school division). Once chosen, fees will be listed at the bottom of the form. *
Culpeper Work Location *
Fauquier Work Location *
Fredericksburg Work Location *
Rappahannock Work Location *
Spotsylvania Work Location *
Stafford Work Location *
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
Home / Non-work Email *

Confirm Email Address *
Work Email

Confirm Email Address
Home/Cell Phone [HIDDEN] Home/Cell Phone [HIDDEN] - ### - ### ####
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
Other Phone Other Phone - ### - ### ####
Other Phone Type

Other 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.
Gender *

Gender Male Female Non-Binary Transgender Female Transgender Male Gender Expansive/Non-Conforming
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
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 (Culpeper): *

Please select your status (Culpeper): Professional Full Time $49.30 per pay period Professional Half Time $25.61 per pay period Education Support Personnel Full Time $26.36 per pay period Education Support Personnel Half Time $14.37 per pay period
Please select your status (Fauquier): *

Please select your status (Fauquier): Professional Full Time $25.05 per pay period Professional Half Time $13.00 per pay period Education Support Personnel Full Time $13.38 per pay period Education Support Personnel Half Time $7.29 per pay period
Please select your status (Fredericksburg): *

Please select your status (Fredericksburg): Professional Full Time $26.82 per pay period Professional Half Time $13.94 per pay period Education Support Personnel Full Time $14.35 per pay period Education Support Personnel Half Time $7.82 per pay period
Please select your status (Rappahannock): *

Please select your status (Rappahannock): Professional Full Time $28.20 per pay period Professional Half Time $14.68 per pay period Education Support Personnel Full Time $15.13 per pay period Education Support Personnel Half Time $8.28 per pay period
Please select your status (Spotsylvania): *

Please select your status (Spotsylvania): Professional Full Time $48.84 per pay period Professional Half Time $26.05 per pay period Education Support Personnel Full Time $26.13 per pay period Education Support Personnel Half Time $14.25 per pay period
Please select your status (Stafford): *

Please select your status (Stafford): Professional Full Time $48.38 per pay period Professional Half Time $25.75 per pay period Education Support Personnel Full Time $25.75 per pay period Education Support Personnel Half Time $14.18 per pay period
Payroll Deduction

I authorize payroll deduction of Association dues by my employer unless I revoke this authorization in writing to the Local Association and School Board. If Employment or Membership is terminated, I understand amount still owing under this authorization shall be deducted from my final pay.
Early Enrollment Pledge

As a participant in the Early Enrollment Membership Incentive Plan, I am eligible to receive—prior to September 1, 2021, but in no event before April 1, 2021—benefits under the NEA Educators Employment Liability (EEL) Program, as well as access to select NEA Member Benefits Programs.

As a condition of eligibility for these benefits, I agree to pay the appropriate unified Active membership dues for the 2021-22 membership year in accordance with established payment procedures. Should I fail to do so, my eligibility to receive benefits under the NEA EEL Program shall immediately terminate. In addition, I shall become liable for the cost of any benefits that were provided to me under the NEA EEL Program prior to September 1, 2021.
Draw your signature into 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?

Mountain View UniServ Membership Application

Mountain View UniServ Membership Application

Personal Information

Dues Classification

Payroll Deduction

Early Enrollment Pledge