Membership Information Form

Professional Number (6-digit number from Teaching License):

Personal Information

First Name:

Middle Name:

Last Name:

Commonly Used Name:

Pronouns:

Do you identify as a member of an equity deserving group?:

Yes

Prefer not to answer

If yes, please identify the equity deserving group:

Month

Date

Year

Mailing Address Line 1:

Mailing Address Line 2 (optional):

City:

Province:

Postal Code:

Preferred (non-employer) E-mail Address:

Primary Phone Number:

Type:

Other Phone Number:

Type:

Can the NSTU share your phone number with a company contracted to contact you by text message on behalf of the NSTU?

Yes

If yes, please indicate which phone number should be used for text messages:

Can the NSTU share your phone number with a company contracted to provide telephone town hall services on behalf of the NSTU?

Yes

If yes, please indicate which phone number should be used for town hall services:

Teacher Certification:

Contract Status:

Position:

Assignment:

Primary School/Site:

Alternate School/Site