MEMBERSHIP FORM

RENEWAL

NEW MEMBER

Membership Year runs from July 1 through June 30

Date ______________________________________

INSTALLMENT PAYMENT FORM

Send completed form with payment to Professional Educators of NC, P.O. Box 17129, Raleigh, NC 27619.

Please complete the information below, and return the form no later

Full Name ____________________________________________ Social Security # _________________________________

than October 31.

Home Address __________________________________________________________________________________________

Bank Draft

City ________________________________________ State ___________________ Zip ______________________________

I authorize Professional Educators of North Carolina

Home Phone __________________________________________ Cell Phone _____________________________________

to initiate electronic debit entries to my:

Email (Home) ___________________________________ Email (School)________________________________________

____ checking account*

I acknowledge that the origination of ACH transactions to my account must

School _________________________________________ City/County ____________________________________________

Position/Subject _________________________________________________ Yrs in Educ. __________________________

Each One Reach One:

Student:

$
$

162

135

Educator: (Jan 1-Jun 30) $120

70

E1R1 Support/First-Year Teacher Rate:

Support:

84

25 (College:___________________________ ___ ) Associate:

First-Year Teacher:

25

84

Partner Membership:

Free!

If you are joining as a Partner Member, list the names of your three member recruits: ___________________________________
________________________________________________________________________________________________________
Recruited by:________________________________________________________________________________________________
METHOD OF PAYMENT

(please print)

Financial institution name:

I have recruited the following: _______________________________________________________

E1R1 Educator Rate:

Educator:

until I have cancelled it in writing.

(see previous page for descriptions)

MEMBERSHIP LEVEL

________________________________________________________
Financial institution city and state:
_______________________________________________________
Account number _____________________________________
Routing number ______________________________________
Signature ______________________________ Date __________
* Please attach a voided check.
Credit or Debit Card Draft

Check Enclosed Payable to PENC for Full Amount

Credit or Debit Card for Full Amount:

Visa

Visa MC AmEx
MC

AmEx

Discover

Discover

Cc# ____________________________________________________

Cc# __________________________________________ CVV Code _____________ Exp. Date ____________________

CVV Code ______________________ Exp. Date _____________

Signature _____________________________________________________________________________________________

Signature ______________________________________________

Installment Payment

(complete form to the right)