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. |