Retired Teachers’ Membership Application

Complete this form to apply for membership in the Retired Teachers’ Chapter.

You must also print and sign this form in order to complete your application.

Date Retired*
MM slash DD slash YYYY
Retirement Number*

You can find this on your first retirement check.
Name*
First Initial Last
Address*
Street Address City State ZIP Code
Phone
School or Dept. Retired From*
Position Held Upon Retirement*
- Teacher
- Para
If you were an Administrator, please answer the following: What School/Department was the last one in which you worked in a capacity covered by a BTU CONTRACT.
BTU/RTC Election Category*
- Secondary
- Elementary
Email Address
Effective on this date hereby request and authorize you to deduct from my monthly retirement allowance the sum of $60 per year in monthly installments of $5.00 for teachers, $30 per year in monthly installments of $2.50 for paras or such other sum as may duly be fixed by Local Union 66, Boston Teachers Union, Retired Teachers Chapter, AFT, AFL-CIO and represents payment of any union dues.
There shall be no change in the amount of the dues deducted without prior notice of the undersigned member.
This authorization shall continue to be in effect until revoked by me by giving you a 60-day written notice.
Today's Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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