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Ohio Retired Teachers Association Membership Enrollment
______________________________________________________________________________________________
Name (As listed with STRS)
Phone Number
______________________________________________________________________________________________
Mailing Address
City
______________________________________________________________________________________________
State
ZIP Code Federal Identification
# (Soc. Sec. #)
last
4 digits for I.D. purposes only
____________________________________________________________________________________________
Were you a member of
Are you a LIFE MEMBER
ORTA last year? YES
NO
of ORTA? YES NO
______________________________________________________________________________________________
Do you receive income from STRS? Year
Retired
YES NO
_____________________________________________________________________________________________
ORTA LIFE ORTA (1/2)LIFE ORTA (1/4)LIFE ORTA ANNUAL
DUES
$300
$150
$75
$20
______________________________________________________________________________________________
Clermont County (Local) Dues LIFE
ANNUAL
$40 $5
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