Membership Application and Professional Dues Statement

May 14, 2012

MISSOURI ASSOCIATION
OF SCHOOL ADMINISTRATORS
(MASA Membership Year is from July 1, 2013 to June 30, 2014)

Name
First Middle Last:
Last 4 digits in Social Security Number:

Position:
School District:
School Address:
City/State/Zip:
Telephone Fax
E-Mail

Home Address (optional):
Home Phone (optional):
Check Membership Status:

Active - Dues for MASA will be .0050 of your 2013-2014 salary, rounded to the nearest dollar. MASA accepts your determination of the amount. Do not list salary, only dues! (Example: $70,000 X .0050 = $350).

Group - MASA membership for multiple central office members. The cost of a district membership is equal to the active membership fee paid by the superintendent of schools and entitles a school district to designate one voting member. (See below to list names of staff members covered.)

Select the MASA district in which you are located:

Are your dues paid by: Individual School District

Payment Information
MASA Active Membership Dues $
MASA School Group Membership Dues $

2013-2014 AASA Active Membership Dues for districts
with enrollments greater than 350 ($436) $

2013-2014 AASA Active Membership for Small Schools
with less than 350 enrollment: ($195) $

MASA Video Library Membership $ (based on enrollment)

TOTAL DUE: $

Method of Payment
Check will be mailed made payable to MASA.
Purchase Order Number: (please invoice)
Credit Card: If you wish to pay by credit card (MasterCard or Visa), please complete your enrollment form, submit and then call the MASA office at 573-638-4825 to ensure confidentiality of your credit card information.

School District Membership Information

Any school district whose superintendent is an active member may purchase one additional school district membership which may be utilized by all central office assistants.

Name, position and e-mail address of designated voting member:

Please list name, position and e-mail address of other central office personnel who may utilize the district group membership (non-voting members):
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