Automatic Dues Deduction

First and Last Name *

Date of Birth *

Retirement Date *

Email *

County Association- (This can be county of residence or county retired from) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

I agree to a voluntary withholding of annual membership dues of $25 for the Kentucky Retired Teachers Association from my November annuity payment from the Teacher Retirement System of KY. I also authorize TRS to share contact and member identification information with KRTA. This authorization will remain in effect until I choose to terminate by written notice to the Teacher Retirement System of KY prior to October 15 of any year. *

I agree

Signature (Please Type Your Full Name) *

Date *

Automatic Dues Deduction

I agree that by signing with an electronic signature that is the legal equivalent of my hand written signature.