CALIFORNIA RETIRED TEACHERS ASSOCIATION

"Membership year -- 1 year from point of joining"

MEMBERSHIP APPLICATION
Please check your selected payment method
(Complete the enrollment form below.)

Dues Deduction:
$3.00 ___
$6.00 ___ (For self and spouse)

I authorize the State Teachers' Retirement System (STRS) to deduct my Association dues. Should the amount of dues be adjusted, as deemed necessary by CRTA, I authorize that the adjusted deductions shall continue unless I notify the CRTA business office in writing to the contrary. To terminate dues deductions, I agree to make my request in writing to the CRTA office.

[_____] Cash: $36.00 annually.
[_____] Life Membership: $720.00 one-time payment,
Signature:_______________________________________________Date:___________
Spouse Name if Joining:___________________________________

ENROLLMENT FORM

Social Security No.:________________________________________Division No.: _____

Name:___________________________________________________________Address:_________________________________________________________
City:______________________State:_____Zip:________Phone:________________________
Retired from:___________________________________________School District:_______________
E-Mail:_____________________________________Born:__________________Age:_____
Please indicate payment method above and mail to:

JEAN FLAKE
AREA XI, Membership Chair
17184 Prado Place,
San Diego, CA 92128-2135
Phone: (858) 487-3874
CLICK to E-Mail Jean Flake
JFLAKE@SAN.RR.COM
RETURN TO "CRTA" AREA XI - "Links" Page
OFFICE USE
CASH...LIFE...INS...DD...DDX2