SEANC
MEMBERSHIP APPLICATION



PLEASE TYPE OR PRINT LEGIBLY

SEANC DISTRICT NUMBER SEANC CHAPTER NUMBER COUNTY/RESIDENCE COUNTY/WORK (IF DIFFERENT FROM RESIDENCE)

19







Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Date Of Birth: ___ ___ - ___ ___ - ___ ___

 

Full Name: ____________________________________________________________________________                               

     ... First ...................................................... Middle ............................................................................... Last ...

 

Phone: _________________________________________
Area Code / Home Phone Number

 

Address: ___________________________________________________________________________________                              

     ... Street/RFD ............................................................ City/Town .............................. State ................................. Zip Code ...            

                      ___________________________________________________________________________________________________

... Department, University, Community College, School System ... Division, Section, School ...  Sub-department, Sub-section, Position ...

 

MEMBER STATUS: (Please check one.) New ____ Renewal ____

Check One

Membership Type

Details


ACTIVE

Active members are current & retired employees of the state of North Carolina and/or persons having membership in or eligible for membership in a state retirement system.

ASSOCIATE

Associate members are SEANC staff members or employees of the State Employees Credit Union.

AFFILIATE

Affiliate members are persons or organizations who support the purposes of SEANC and who have been approved for membership by the SEANC Board of Governors. (No member benefits are effective until approval is granted.)
Dues Schedule
ACTIVE MEMBER (employed) = $48.00__________ ACTIVE MEMBER (retired) = $24.00__________
ASSOCIATE MEMBER = $48.00__________ AFFILIATE MEMBER = $48.00__________

 

Check One

Dues Payment Plan

Amount/Pay Plan


Monthly

$________________ by payroll deduction


Bi-weekly

$________________ by payroll deduction


Annual

$________________ by check

 

    I, the undersigned, hereby authorize my employer to deduct SEANC membership dues from my wages on a monthly basis, in such amounts as are currently established pursuant to the SEANC Bylaws, or in such adjusted amounts as may be approved by the membership subsequent to the date of this authorization. This authorization shall continue until canceled by me by written notice to the SEANC Central Office. Monthly payment of dues is not refundable.

Signature: _________________________________________________________________

Date: ________________________

Recruited by: ___________________________________________________________________

Member desires information on Term Life and AD&D Insurance Programs: Yes ____ No ____

SEANC membership dues are not deductible as charitable contributions for Federal or North Carolina income tax purposes.