Membership Application for the PI OMEGA CHAPTER Phi Theta Kappa International Honor Society

Please clearly print or type all information requested.

Name:

First: Middle: Last:

Address:

Street: City, State: Zip:

Social Security Number (required for membership processing): ___________________________

Email address: _________________________________________________________________

Telephone number: _____________________________________________________________

Area code Phone number

Expected graduation/transfer date: Month: ________________ Year: ________________

Academic Major:_____________________________________________________________

By completing this form, I certify the following:

§ I have met all membership eligibility requirements for Phi Theta Kappa.

§ I currently enjoy the full rights of citizenship, freedom, and privileges of my country (International students attending college on a United States visa and who possess full right of citizenship of their country are eligible for membership).

§ I understand that there is a required GPA (3.50 for admission, 3.25 to maintain) for membership in Phi Theta Kappa and agree to notify my chapter advisor (Lori Garrett) immediately if at any time I fail to maintain my chapter's maintenance GPA.

§ I promise to uphold the standards of Phi Theta Kappa International Honor Society.

Signature: ______________________________________ Date: _______________

(COMPLETE INFORMATION ON BACK BEFORE SUBMITTING)

Payment option form:

Check One:

______ I am applying for REGULAR MEMBERSHIP.

§ I understand that I must submit this fully completed form and my full one-time membership fee of $65, payable to DACC, to the DACC Cashiers Office, first floor, Vermilion Hall.

§ I understand that my membership will not be officially submitted until my payment is submitted.

______ I am applying for REGULAR MEMBERSHIP with a payment plan.

§ I understand that I must submit this fully completed form and my first installment of the regular membership fee of $65, payable to DACC, to the DACC Cashiers Office, first floor, Vermilion Hall.

§ I will be responsible to the College for paying the remainder owed no later than 30 days after my first payment.

§ I understand that my membership will not be officially submitted until the entire $65 has been paid.

Amount of my first payment: (minimum $20) _______________________

Estimated date of next payment: _____________________

______ I am applying for HARDSHIP SCHOLARSHIP FUNDS.

§ I understand that I must submit this fully completed form and a brief written explanation of my special circumstances to Lori Garrett, Director of Scholars Programs, Room 282 Mary Miller Center, Danville Area Community College, 2000 E. Main St., Danville IL 61832.

§ I understand that if accepted, I will be notified and my membership fee will be paid for by a Hardship Scholarship. As a condition of the scholarship, I agree to participate in at least two chapter activities during the semester in which I join.

§ If I fail to participate in at least two activities, I will be billed in full for my membership and will be responsible for full payment to the College.

For more information, or for consideration of other options, please contact

Chapter Advisor Lori Garrett by email at scholars@dacc.edu or at 217-443-8796.