Monthly ACH Membership RegistrationUse the form below to register for monthly ACH membership payments. ACH Membership Payment If you are currently a PEI member, please login to your account before filling out the ACH payment form. Current Membership Status*NewRenewalName* First Last Gender*MaleFemaleAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Email* This will be used as your account usernamePrimary Phone Number*Alternate Phone NumberDate of Birth* MM DD YYYY Last 4 digits of SS#*School/Employer*School BuildingSchool Email Job Title*How did you hear about PEI?Authorization Agreement for Direct Payment Amount* I agree to this authorization agreement.I hereby authorize Professional Educators of Iowa to initiate debit entries to my account indicated below and to debit the same to such account.Account*Checking AccountSavings AccountRouting Number*(9 digit number)Account Number*Membership Category*PEI Professional Membership: $20/monthPEI Supporting Membership: $7/monthPayment Date*1st of the month15th of the month22nd of the monthAcknowledgement* I acknowledge.I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authorization is to remain in full force and effect until PEI has received written notification from me of its termination in such time and in such manner as to afford PEI and TruBank a reasonable opportunity to act on it. Note: All written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Coverage by PEI will not go into effect until a membership application is activated and you receive written or electronic notice. By submitting this application I affirm I do not intend to use PEI services for any professional exposures arising prior to membership effective date or after membership expiration. For applicants in need of immediate assistance with professional exposures arising from a nexus of events which began outside the effective membership dates please speak with a PEI representative at (515) 221-2330 to determine if you are eligible for PEI membership. Such applicants may at PEI’s sole discretion be eligible for membership but, regarding occurrences falling outside effective membership dates, are NOT eligible for insurance payouts, indemnification of liability incurred, or legal assistance. PEI assumes no risk for any actions or incidents which occur outside a member’s effective membership dates. Misrepresenting or concealing the inception date of a claim is grounds for denial of coverage and termination of membership.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.