Signor agrees and understands that by electronically signing the Membership Enrollment Form, all electronic signatures are the legal equivalent of my manual/handwritten signatures and are meant to authenticate membership with the Southern Nevada Black Educators Initiative. I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. Under penalty of perjury, I herewith affirm that my electronic signature, and all future signatures, were signed by myself with full knowledge and consent and I am legally bound to these terms and conditions. * For more information about services available to members, contact Southern Nevada Black Educators Initiative at: (702)482-8524 Yes, I agree to the above statement. Membership Type * Educator Community Member Title * Ms. Mrs. Mr. Dr. First Name * Last Name * Personal Email * School Email Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Job Class Licensed Educator Other Licensed Professional Years of Service 0-3 4-8 9-14 15+ School Site License Expiration Date * MM DD YYYY *The following information is optional and failure to answer it in no way will affect your membership status. Birth Date MM DD YYYY Ethnicity Black or African American Asian White American Indian or Alaska Native Hispanic or Latino or Spanish Origin Not Hispanic or Latino or Spanish Origin Other My electronic signature authorizes SNBEI to advocate for me before school elected officials, local and state representatives in matters that impact Black educators, Black licensed professionals, Black pre-service teachers and Black students in Nevada. I understand that SNBEI is unauthorized to represent me in investigatory meetings, disciplinary hearings and cannot file grievances against my employer on my behalf. I fully understand that SNBEI is not a collective bargaining unit and does not have legal authority to negotiate contracts to determine terms of employment such as but not limited to, pay, benefits, hours and leave. * With full knowledge of the above, I hereby agree and authorize SNBEI to deduct the dues that are established annually for this membership year and each year thereafter provided that I may revoke this authorization by giving written notice to that effect to SNBEI between August 1 and August 30, of any calendar year. Dues are paid on an annual basis and are deducted from my credit or debit card on file. As a member, I am obligated to pay the entire amount of dues for the membership year. I understand that if I resign my membership in SNBEI, I am still obligated to pay the remaining balance for that membership year. Yes, I agree to the above terms and conditions statement. Member's Signature * First Name Last Name Thank you!
