DO NOT USE THIS FORM IF YOU HAVE BEEN PREVIOUSLY
EXPELLED FROM THE
FRATERNITY! | |||
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 * | ||
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 | 4/21/2018 | 188f2d022b28cfb2d6ccfc34f69c0ded |