Printable ASTA Membership Application

Please print this membership form and mail to:
Arkansas State Teachers Association
705 South Pine St., Suite 3
Cabot, AR 72023

         Please check type of Membership

Professional ($2 million liability insurance)	$180
Student (includes student teaching insurance)	$25
Retired Educator	$25
Associate Member (newsletter only)	$25

Method of Payment

Credit Card: ___MC ___VISA ___Discover ___AE

Credit Card #________________________________________________

Expires ____________________________________________________

Signature: __________________________________________________

___Check, make payable to ASTA-AAE

SS#_______________________________________________________

Birthdate___________________________________________________

Name______________________________________________________

First                         MI                          Last

Address_____________________________________________

City________________________________________________

State_______________________________ Zip______________

Home Telephone (________)_____________________________

E-mail_______________________________________________

School Name__________________________________________

District______________________________________________

County______________________________________________

Subject/Grade(s) Taught__________________________________

Referred by___________________________________________

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