WTA New Member Sign Up Form Printout v Sept 28 2024

Saturday, Septembe
r 28, 2024
West Texas Alliance - New Member Sign Up Form
Personal Information
Full Name
Mr. Mickey Mouse
Address
123 I LIve Here
LA, ca, 797885
Date of Birth
Friday, January 1, 2010
Phone Number
(915) 543-2178
Employment Information
Employee ID#
District
Clint ISD
Campus/Department
chs
Work Phone Number
(915) 544-4434
Job Title / Assignment
test
Membership Dues & Responsibilities
Do you need to cancel another association? If no select None, if yes choose the association below. Note: WTA will cancel your other membership.
SEA
Dues (Payroll Deduction)
Responsibility of Dues
I understand it is my responsibility to monitor my dues and notify WTA of my employment separation from SISD/CISD/YISD/Other district listed.
Paycheck Deduction
I understand my dues will be automatically deducted from my paycheck.
Electronic Signature Consent
Signature
Item - signature 1
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