WVSEA - Student Program

WVEA Student Program
WVSEA/SNEA 2011-2012
1558 Quarrier Street
Charleston, WV 25311

Please print, complete and mail the registration form below with payment.

Name (last, first, m.i.):

_______________________________________

Mailing Address:

_______________________________________

City, State, Zip:

_______________________________________

Phone:

(_______) _______ - _____________

Social Security Number:

______ - ______ - ____________

College:

_______________________________________

Year:

Freshman
Sophomore
Junior
Senior
Graduate

55

00

000

0000

Position Code 16 Payment Method 1

Association	Membership Code	Annual Payment
SNEA	60	$15.00
WVSEA	60	$13.00
Local Chapter Dues	60	$___________
TOTAL:		$___________

Charge my credit card:
Type of Card:
Account Number:
Expiration Date: /
Name on Card:

Signature: ______________________________

The WVSEA membership year runs August 1, 2011 to August 31, 2012. If you are eligible to join WVEA as a member in another membership category, you must do so.

Member's Signature ________________________________

Date: ____ / ____ / _____

EmailAddress: ________________________________________________

Retain a copy for your records.