Membership Application

"*" indicates required fields

OPEA MEMBERSHIP APPLICATION

MEMBERSHIP INFROMATION

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number or Employee ID Number*

COMMUNICATION PREFERENCES

Preferred Contact Phone #

Personal Email*

Work Email*

Would you like to opt-in to the membership newsletter?

Yes

Agency Information

Agency Name*

Work Location

City State

Who introduced/referred you to OPEA?

MEMBERSHIP SELECTION

OPEA’s standard dues are $18 per month. Annual dues: state employees - $216; retirees - $72; associates - $40; corporate affiliates - $300 (Contact OPEA for more information.) Contributions or gifts to OPEA are not deductible as charitable contributions for federal income tax purposes. However, dues payments are deductible as a miscellaneous itemized deduction. Your $18 monthly dues payment can include a ($2.25) contribution to the OPEA-Political Action Committee.

Membership Preferences*

Active State Employee Basic Membership - ($18/month payroll deduction)

Active State Employee Basic Membership Including OPEAPAC Donation - ($18/month payroll deduction)

Active State Employee OPEAPAC+ Membership Including An Increased OPEAPAC Donation - ($23/month payroll deduction)

Retired State Employee Basic Membership - ($6/month Deducted from OPERS)

Retired State Employee Basic Membership Including OPEAPAC Donation - ($6/month deducted from OPERS)

Date Signed*

Authorization to Deduct from Payroll*

By signing this form, I hereby authorize the state of Oklahoma to deduct from my pay the amount checked above required to purchase dues in the Oklahoma Public Employees Association, subject to my right to revoke this order by written notice to my employer.

Signature*

Name

This field is for validation purposes and should be left unchanged.