2012-2013 MEMBERSHIP APPLICATION
Name: ________________________________________
last first middle
Address:
Street___________________________________________
City:________________________
County:___________________Zip:_____________
Telephone:___________________
e-mail:______________________
Birthdate:________ __________ _________
year month day
Year Retired:________
School District:_______________________________________
Subject or Grade:_____________
Position: ___Teacher ___Principal ___Supervisor
Level: ___Elementary
___Middle School ___Junior High___High School
Number of years taught ____
Positions held in WBET____________________________
Please indicate your wishes.
Dues $10.00 ____
* Mailing Update $4.00 ____
* Mailing Directory
$1.50 ____
Total to be submitted ____
Make checks payable to WBET and send along with this completed form
to:
Mrs. Shirley Dailey
1804 E. Main St.
Endicott, New York 13760
*service to members unable to attend
any meetings.
(To receive your membership card, please send a self address postage stamped envelope to Shirley Dailey)
