MEMBERSHIP APPLICATION

Please Print

Name:_________________________________   Social Security #:______________________

Mailing Address:_________________________  City________________________State:_______

County:____________________________________                                     Zip:______________

Phone#:____________________  Cell#:_________________          Birthday:_________________

E-Mail Address:_________________________________________________________________

Would you like to receive a reminder call before each meeting ?        ______Yes                  _____No

To pay your annual dues to the state NMAER via payroll deduction

        -------------------  read and sign below -------------------

I hereby authorize the Educational Retirement board to deduct NMAER state dues from my

retirement check in the amount of $2.08 a month.  I understand this authorization makes me

a continuing member of the NMAER state association and can be canceled only by

a written notice from me.

__________________________________            _________________

    (Signature of Retiree)                                                  (Date)

______Already on Automatic state dues

______$25.00 enclosed for annual state dues

______$10.00 enclosed for annual local dues

                                    (DUES ARE NOT TAX DEDUCTIBLE)

Make checks payable to SJAER

Mail to:  SJAER Membership Chair, Karen Ransom

              900 Hare Street,   Bloomfield, NM  87413-5206

          Sponsored by Karen Ransom                 Unit Sponsored by San Juan AER