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PLEASE PRINT

Last Name: First Name: M.L:
Address:
Street
City State Zip Code
Home Phone Cell Phone

Home/Non-School Email Address

School: Date:

TO NASHUA BOARD OF EDUCATION:

I hereby authorize you to deduct UNION dues from my earnings with the next paycheck and continuing in
equal installments in an amount equal to the UNION dues as set by the membership in accordance with
provisions of the Constitution of the Nashua Teachers’ Union. This amount shall be paid the Treasurer of the
Nashua Teachers’ Union, Local 1044, AFT, AFT-NH, AFL-CIO. This authority shall remain in full force and
effect for all purposes while I am employed in this school system, or until revoked by me in writing between
September 1*t and September 15" of any given year.

EMPLOYEE SIGNATURE
STATUS: Part-time Continuing Sub Chapter I School Nurse
Federally Funded Regular (Contract) School Psychologist:

51

Return this form to:
Nashua Teachers’ Union
7C Taggart Drive
Nashua, NH 03060

Due, contributions, or gifts to the Nashua Teachers’ Union are not deductible as charitable
contributions for federal income tax purposes. Dues paid to the Nashua Teachers’ Union, however,
may qualify as business expenses, and may be deductible in limited circumstances subject to
various restrictions imposed by the Internal Revenue Code.

52

EMPLOYEE S MAME (PLEASE PRIA SOCAL SECURITY MINAS EI
ADDRESS (Strect Crh Siete and fis)
HOME PHONE SCHOOL

53

APPENDIX

INSURANCE DEDUCTION AUTHORIZATION

Last Name First Ml.
Effective Date Social Security Number.

Address

School

Amount to be deducted each pay-period: $

To the Board of Education:

| hereby authorize you, according to arrangements agreed upon with the Nashua Teachers' Union, Local 1044, AFT,
NHFT, AFL-CIO, to deduct from my salary and transmit to said organization, monies for insurance premiums. |
hereby waive all right and claim to said monies so deducted and transmitted in accordance with this authorization,
and relieve the Board of Education and all its officers from any liability therefore. This authority shall remain in full
force and effect for all purposes while | am employed in this school system, or until revoked by me in writing or
modified through the issuance of another authorization between September 1st and September 15th of any given
year or at such time as a qualifying event including but not limited to an effective date of retirement, termination or
resignation.

Member Signature: Date:

STATUS: Part-Time Continuing Sub
Title | Regular (contract)
Federally Funded School Nurse

School Psychologist

Return this form to:
Nashua Teachers' Union

7C Taggart Dr.
Nashua, NH 03060

54

APPENDIX

DESIGNATED AREAS

Architecture and Construction

Arts, Audio-Visual Technology and Communications

Blind and Vision Disabilities

Childhood Development and Education

Comprehensive Business Education

Comprehensive Family and Consumer Science

Comprehensive Marketing Education

Comprehensive Technology Education

Culinary

Deaf and Hearing Disabilities

Early Childhood - Nursery to Grade 3

Early Childhood Special Ed Nursery to Grade 3

Education Technology Integrator

Elementary Education Kindergarten - Grade 6 with elementary education HQT status
Engineering

English /Literacy (including middle school certification)

ESL; English for Speakers of Other Languages

Foreign Language by certification (subject to being HQT and having taught one year in the last five years)
Guidance/School Counselor

Health Education

Health Science

Hospitality and Tourism

Human Services

Library Media Specialist

Manufacturing

Mathematics (including middle school certification)

Music Education

Physical Education

Reading and Writing Specialist

School Nurse

School Psychologist

School Social Worker

Science by certification in specific subjects (including middle school science as a subject area)
Science, Technology, Engineering and Mathematics

Social Studies (including middle school certification)

Special Education (including categorical areas requiring general or early childhood special education)
Speech Language Pathologist or Speech Specialist

Visual Art Education

55

APPENDIX

MOU/NEGOTIATION LANGUAGE

The Nashua Board of Education and the Nashua Teachers’ Union, AFT Local 1044, hereby agree to the following:

DATE:

The Nashua Board of Education shall grant a leave of absence with pay for a member of the bargaining unit
elected to serve as the President of the Nashua Teachers’ Union for the duration of the President's term(s)
of office.

The leave shall commence with the effective date of the term of office for the President provided the NTU
gives written notice of at least thirty (30) days prior to the commencement of each term of office.

During such leave of absence with pay, the President shall continue to receive and retain all of his/her
wages, including step and track movement, if eligible, rights, benefits including but not limited to medical
and dental insurance, NH Retirement System, and seniority as a member of the NTU bargaining unit;
except that all sick leave accumulation shall be frozen for the duration of the leave of absence. Upon
returning from leave of absence, the President shall resume earning sick leave in accordance with the
collective bargaining agreement. The Nashua Teachers’ Union shall be solely responsible for any
additional compensation and benefits provided by the Union in addition to those provided by the Nashua
School District under the collective bargaining agreement.

The Nashua Teachers’ Union agrees to reimburse the Nashua School District for the full cost of the wages
and benefits for the President, and to indemnify the District against any and all liabilities associated with the
leave of absence, including but not limited to workers’ compensation. The method and manner of
reimbursement shall be agreed between the parties to meet the administrative needs of the District.

The parties agree that this Memorandum of Understanding may be the subject of negotiations for a
successor agreement but shall continue in full force and effect in subsequent collective bargaining
agreements unless modified in writing by the parties.

NASHUA BOARD OF EDUCATION NASHUA TEACHERS’ UNION

LOCAL 1044 AFL-CIO

Adam Marcoux, President

, Clerk Patrick Johnson, Secretary

56

APPENDIX

DELTA DENTAL PREMIER NETWORK

Group #127 Sublocations #4633 (Teachers) and #5182 (Retirees)

Coverage A
Diagnostic/Preventive

Coverage B
Basic Restorative

Coverage C
Major Restorative

Coverage D
Orthodontics

Deductible: $0 There is no deductible on your program

Covered at 100%*

Covered at 85%*

Covered at 70%*

Covered at 50%*

Diagnostic: Basic Restorative: Major Restorative: Orthodontics:
Evaluations — two in a 12- | Amalgam (silver) fillings | Removable and_ fixed | Correction of crooked
month period Composite (white) fillings | partial dentures (bridge); | teeth for dependent
(anterior teeth only) complete dentures children to age 19
X-rays (complete series or
panoramic film) once in a | Oral Surgery: Rebase and reline
3-year period; bitewing x- | Surgical and routine | (dentures)
rays once in a 12-month | extractions
period; x-rays of individual Crowns
teeth as needed Endodontics:
Root canal therapy Onlays
Oral cancer screening —
once in a 12-month period | Periodontics: Implants
Periodontal maintenance
Preventive: (cleaning)
Cleanings — four in a 12- | Four cleanings are
month period (routine | covered in a 12-month
and/or periodontal, in any | period; this can be routine
combination) and/or periodontal, in any
combination.
Fluoride twice in a 12-
month period to age 19 Treatment of gum disease
Clinical crown lengthening
Space maintainers to age | — once per lifetime per site
16
Denture Repair:
Sealant application to | Repair of a removable
permanent molars, once in | denture to its original
a 3-year period per tooth, | condition
for children to age 19
Emergency Palliative
Treatment
Contract Year Maximum: $2,000 per person (Coverage A, B, and C combined) | Orthodontic Lifetime
beginning each September 1st** Maximum: $2,000 per
Age Maximum: Coverage for children up to age 26, except as noted above. person

*Benefit percentages shown are based upon the actual charge submitted to a maximum of the approved fees, or
Delta Dental’s allowance for non-participating dentists.
**Open enrollment effective date: October ‘st.

57