If you will not be paying online, please download and complete a membership form. C. Scott Miller, Treasurer NEA-GLBT Caucus 2321 East 4th Street, #C438 Santa Ana, CA 92706 First Name* Last Name* Address 1* Address 2 City* State* Postal Code* Phone* Email* Please indicate the NEA Region in which you reside. REGION* Mid-Atlantic Midwest Northeast Pacific Southeast West Please indicate race (optional): RACE American Indian Asian / Pacific Islander Black Hispanic Multi-Racial White Please indicate sexual orientation (optional): Sexual Orientation Bisexual Gay Lesbian Straight Ally Transgender Please list Gender (optional): GENDER Female Male Transgender Membership Levels: Active $25 NEA Membership (including Staff & Life) - Full Voting Rights Active ESP $15 NEA Membership (including Staff & Life) - Full Voting Rights Associate $15 NEA-GLBTC supporter (need not be an NEA member): No Voting Rights Student $5 NEA student member. All rights of an Active member. Retired $5 NEA retired member. All rights of an Active member. Domestic Partners / Married $35 (both eligible for Active membership) Unified National /State Active $40 Must be eligible for active membership at the national and state level.(CA, OR, PA, and WA residents only) Foundation Membership: Pink Triangle ~$100 ~ Receives all benefits/rights associated with Active membership in addition to recognition in the Fall Caucus Newsletter and the GLBTC Annual Dinner Program. Labyrinth ~$200 ~ All of the above and you may place a business card size ad in two caucus newsletters. Rainbow ~$500 ~ All of the above and you may place a business card size ad in each of the four caucus newsletters. Ichabod Crane Society ~$1000 ~ All of the above and two tickets to this year’s dinner. Type the text from this image. Use digits only. Security Code If you will not be paying online, do not PREVIEW but please print out this FORM. . See mailing address at top of this page. If you are paying online with a name other than the one on this reservation form, it is VERY IMPORTANT that you include a note/comment on the PayPal Payment form stating both names so that we may reconcile our database with PayPal.
If you will not be paying online, please download and complete a membership form.
C. Scott Miller, Treasurer NEA-GLBT Caucus 2321 East 4th Street, #C438 Santa Ana, CA 92706
If you will not be paying online, do not PREVIEW but please print out this FORM. . See mailing address at top of this page.
If you are paying online with a name other than the one on this reservation form, it is VERY IMPORTANT that you include a note/comment on the PayPal Payment form stating both names so that we may reconcile our database with PayPal.
