APPLICATION FOR
REGULAR MEMBERSHIP
and
PAYROLL DEDUCTION AGREEMENT
I hereby apply for regular membership in, and authorize the East Side Union High School District or its agent to withhold from each of my monthly salary warrants (not to exceed ten warrants annually) the sum of three dollars ($3.00) and to transmit said sum to the
Benevolent
My membership and this authorization shall be in full force and effect until revoked or changed in writing by myself or by the B.A.E.S.E.
The effective date shall be the next payroll period following receipt this authorization by the E.S.U.H.S.D.
______________________________ ________________ ___________________
indicate category * * * cert class admin
Name (please
PRINT legibly) Site Date
______________________________ ________________
Signature Social Security No.
__________________________________________________ ___________________
Home Address City Zip Home Phone
PLEASE
THIS FORM TO THE PERSONNEL OFFICE AT THE D.O.