WVSEA - Student Program

WVEA Student Program 
WVSEA/SNEA 2013-2014
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 00   000 000 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, 2013 to August 31, 2014. 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.