Member Information

*First Name:

*Last Name:

*Billing Address:

*City:

*State:

*Zip Code:

*Phone Number:

*Personal Email Address:

*Work Location:

Checking Account Information

Please make sure to enter the complete Electronic Payment Number (ACH) with your
Account Number (even if they are zeros), or your payment will not go through

Routing number is a 9 digit number

*Account Type:

*Routing Number:

*Account Number:

*I Agree:

I acknowlege that I am an approved signer on the above account and I hereby agree to have my account debited as of this date for the amount specified. If the draft to my account fails, I agree to pay any related NSF fees.

Annual Payment Authorization: Yes! I hereby agree to pay the annual (Sep 1 to Aug 31) dues, fees, and assessments established by the three associations in consideration for the services the union provides. I understand that those annual amounts are subject to periodic change by the governing bodies of the associations. I authorize on a continuing basis, and regardless of my membership status, the payment of those annual amounts established by the three associations through the method selected above unless I revoke this authorization in accordance with the terms established by my state and local associations.

I understand that checking and signing this box constitutes a legal digital signature confirming my understanding and agreement to the following: I authorize the Alpine Education Association to charge my checking/savings account, as provided above, for annual dues. I will receive a breakdown of prorated monthly due. I further authorize those payments to be made through the initial membership year ending August 31, and recurring annually thereafter, payable per the schedule and in the amounts conveyed to me.

I understand that if the governing bodies of AEA or its affiliates change the annual dues amount or the dues payment schedule, the Alpine Education Association will notify me in writing not less than 10 days before processing any changes to the amount described in the payment summary, and I will have the opportunity to make changes to my payment method or opt out at that time.

I understand that this authorization continues year-to-year and shall remain in effect until the earlier of: 1) the termination of my eligibility to maintain membership in the Association; or 2) my written notice to terminate this authorization, which must be sent to the Alpine Education Association at 557 W.Center Street,PL. Grove, UT 84062 and include my name, address, employer, and membership number, if you know it. I understand that termination of this authorization will take effect 7 days after receipt by the association. I further understand that termination of this authorization, or the rejection of any charge or debit, shall not constitute the termination of my membership or dues obligation.

* Signed: