International Member Reclaim Form

INTERNATIONAL MEMBER RECLAIM FORM
DO NOT USE THIS FORM IF YOU HAVE BEEN PREVIOUSLY EXPELLED FROM THE FRATERNITY! ' * ' Denotes required fields. If you need assistance, please contact the Membership Department at 404-284-5533 (USA)
		Member ID * [ Also known as your 9-digit Control Number ]
	Last Chapter of Affiliation * (listing by District-Chapter)	Chapter of Initiation * (listing by District-Chapter)	Initiation Date *

	Please provide current information below:
	First Name *	Middle Name	Last Name *
	Home Address *	Address Line 2	City *
	State *	Zip *	Country *
	Preferred Contact Number *	Email Address *

INTERNATIONAL MEMBER DUES and OTHER FEES
	UNIT PRICE	QUANTITY	TOTAL
	International Member Dues $300.00	1	$
	Re-instatement Fee $3.00	*	$
	Late Fee $5.00	*	$

	Life Membership Fee $2,500.00	* [ Select quantity if you choose to apply ]	$
	Partial Life Membership Fee $1,250.00	* [ Select quantity if you choose to apply ]	$

		GRAND TOTAL	$
	Guest	10/19/2018	bc1bbc761e9956c58916b36033941064