Test Page A Payroll deduction TEST YES-I want to join with my colleagues and become a member of my local association, the Massachusetts Teachers Association, and the National Education Association. I hereby request and voluntarily accept membership in these associations, which shall continue on a voluntary basis from year to year. I agree to abide by the bylaws and constitutions of the associations. To support the associations' goals and to receive the advantages and benefits of membership, I agree to pay the full annual dues in each year of voluntary membership, owing at the start of each year and payable by payroll deduction, check, or other payment methods if available.* By checking the box at the left, I affirm that I understand and agree with the statement above. (Check box for digital signature) TODAY'S DATE* Date Format: MM slash DD slash YYYY Name* First Middle Last Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*The phone number is especially important for us all if there are problems with your payment.Phone TypeHomeWorkCellEmail*Personal email is preferred. We email a copy of your electronic submissions to you. Enter Email Confirm Email College*Note: You may teach at more than one Massachusetts community college. In the following list, you should choose the one which sent you to this page. If this does not apply, choose the one at which you currently teach the most.Select OneBerkshire Community CollegeBristol Community CollegeBunker Hill Community CollegeCape Cod Community CollegeGreenfield Community CollegeHolyoke Community CollegeMassasoit Community CollegeMassBay Community CollegeMiddlesex Community CollegeMount Wachusett Community CollegeNorth Shore Community CollegeNorthern Essex Community CollegeQuinsigamond Community CollegeRoxbury Community CollegeSpringfield Technical Community CollegeEthnicityPlease ChooseAsianBlackHispanicAmerican Indian/AlaskaWhite (not Hispanic origin)Native Hawaiian/Pacfic IslanderOther Racial or Ethnic MinorityUnknownPrefer not to discloseGenderPlease chooseMaleFemaleNon-BinaryPrefer not to discloseMembership year.July 1, 2020 to June 30, 2021Position:*Part-time Faculty (DCE and Day Part-time)Part-time Professional StaffFull-time FacultyFull-time Professional StaffSemesters in which you expect to be teaching* Fall (September through December) Spring (January through May) Winter (Short Intersession) Summer 1 Summer 2 Semesters in which you expect to be working* Fall (September through December) Spring (January through May) Winter (Short Intersession) Summer 1 Summer 2 Date of Hire (Approximate is OK)* Date Format: MM slash DD slash YYYY Dues for Full-time Members You were hired during this time period 07/01 – 11/14 11/15 – 01/31 02/01 – 04/14 04/15 – 06/30 Your Dues $1032.00 $774.00 $516.00 $258.00 Dues Breakdown* MCCC $332.00 $249.00 $166.00 $83.00 MTA $500.00 $375.00 $250.00 $125.00 NEA $200.00 $150.00 $100.00 $50.00 Dues for Part-time Members If you expect to earn Under $9,000 per year Over $9,000 per year Your Dues $218.00 $312.00 Dues Breakdown* MCCC $99.60 $99.60 MTA $51.00 $102.00 NEA $67.40 $110.40 PLEASE CHOOSE - If you expect to earn per year*Under $9,000Over $9,000PLEASE CHOOSEPLEASE SELECT THE TIME PERIOD WHICH INCLUDES YOUR DATE OF HIREFull-Time Hired 07/01 – 11/14Full-Time Hired 11/01 – 01/31Full-Time Hired 02/01 – 04/14Full-Time Hired 04/15 – 06/30Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA Only for those who already pay MTA and/or NEA ElsewhereI already pay MTA or NEA dues at another school or college. If you pay any of these dues/fees through another MTA/NEA-AFFILIATED school system, pay only the MCCC and/or MTA and/or NEA dues which you do not already pay. MTA NEA I pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay MTA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONI pay NEA dues through:*YOU MUST SUPPLY THE NAME OF THE SCHOOL SYSTEM OR COLLEGE FOR VERIFICATIONTotal $0.00 *MCCC membership includes membership in the Massachusetts Teachers Association (MTA) and the National Teachers Association (NEA). These large organizations provide services that the MCCC cannot provide, such as legal assistance. MTA membership comes with many cost saving benefits. Check out the MTAB (MTA Benefits) link on the MCCC home page.I authorize my public employer,*Select oneBerkshire Community CollegeBristol Community CollegeBunker Hill Community CollegeCape Cod Community CollegeGreenfield Community CollegeHolyoke Community CollegeMassasoit Community CollegeMassBay Community CollegeMiddlesex Community CollegeMount Wachusett Community CollegeNorth Shore Community CollegeNorthern Essex Community CollegeQuinsigamond Community CollegeRoxbury Community CollegeSpringfield Technical Community Collegeto deduct in each pay period a pro rate portion of the annual dues of the Massachusetts Community College Council the Massachusetts Teachers Association and the National Education Association. I understand that annual membership dues for the associations are subject to periodic change by the governing bodies of the associations, and I authorize the deduction of modified dues as may apply. This authorization shall be irrevocable for the period of one year from the anniversary date of authorization (unless my employment ends during the payroll year). Said authorization shall continue from year to year unless I revoke it by notifying the treasurer of the local association in writing and filing a copy of said notice with my employer.* By checking the box at the left, I affirm that I understand and agree with the statement above. (Check box for digital signature) Name* First Middle Last The button below generates an authorization by you for payroll deduction. You will receive an email confirmation that you have elected this option. Dues/fees will be automatically deducted from your pay by your college until you notify us otherwise.