Application for Incentive Rebate

I. WE HEREBY CERTIFY THAT WE HAVE MET THE REQUIRED PAYMENT SCHEDULE OUTLINED IN SECTION II OF THE INCENTIVE REBATE POLICY AND HAVE PAID TO OEA AT LEAST 50% OF OUR TOTAL ANNUAL OBLIGATION BY MARCH 15. WE ALSO UNDERSTAND WE MUST CONTINUE TO PAY ACCORDING TO OUR STATEMENT IN ORDER TO QUALIFY FOR OUR SECOND INSTALLMENT.

Attestation to the above statement: Please enter your name.

Full Name

First Name Last Name

Email to receive a copy of submission:

example@example.com

	SAME LEVEL OF MEMBERSHIP AS LAST YEAR	INCREASE IN MEMBERSHIP	100% ENROLLMENT
CHECK ONLY ONE

II. WE ARE APPLYING FOR A REBATE IN THE FOLLOWING CATEGORIES (PLEASE CHECK THOSE THAT ARE APPLICABLE).

	Select all that apply
D. 100% OF ANNUAL DUES OBLIGATION HAS BEEN PAID BY JAN. 1
E. LOCAL DUES OF $25 OR MORE
F. FULL-TIME RELEASE OFFICER
G. 1/2-TIME RELEASE OFFICER
H. FULL-TIME SECRETARIAL/CLERICAL HELP
I. 1/2-TIME SECRETARIAL/CLERICAL HELP

CATEGORIES - If you selected a category above you MUST complete the corresponding section below.

E. AMOUNT OF LOCAL DUES PER MEMBER$

F. #OF HOURS PER WEEK

G. # OF HOURS PER WEEK

H. #OF HOURS PER WEEK

I. # OF HOURS PER WEEK

J. LOCAL OFFICE, AVAILABLE TO OTHER LOCALS FOR ASSOCIATION MEETINGS (if not do not have a local office please place NA in the information below)

ADDRESS: *

HOURS OF OPERATIONS: *

DAYS PER WEEK: *

III. CERTIFIED BY:

AFFILIATE INFORMATION:

AFFILIATE NAME: *

AFFILIATE PRESIDENT: *

First Name Last Name

ADDRESS: *

PERSON COMPLETING THIS FORM: *

First Name Last Name

TITLE:

PHONE #(HOME):

Area Code Phone Number

PHONE #(SCHOOL):

Area Code Phone Number

E-MAIL ADDRESS:

AFFILIATE TREASURER:

First Name Last Name

DATE:

Month Day Year Date Picker Icon

***APPLICATION DEADLINE MARCH 20TH***