Membership Information:
Induction Responce Form

Please print carefully:

Name as you want it to appear on your certificate _________________________________

First Name: _______________________ Last Name: _____________________________

Street Address: __________________________________________________________

City: _______________________ State: ____________ Zip Code: __________________

Social Security # _____-____-________ Phone: (h) _____________ (w) ______________

E-mail: _________________________________________________________________

Transfer or Graduation Date: _____________ Transfer Institution: ____________________

Membership Status (please check):

____ Regular ____ Enhanced (will participate in local activities)

1. Are you willing to chair an activity?
   • ___ yes ___ no
2. On which committee would you like to serve? (you may choose more than one)
   • ____ Scholarship _____ Service ____ Leadership ____ Fellowship
3. Would you be willing to travel to various meetings either locally or nationally?
   • _____ Regional Leadership Conference, early fall
   • _____ Regional Honors Institute, late fall
   • _____ Regional Convention, early spring
   • _____ International Convention, early April
   • _____ International Honors Institute, early summer
   • _____ Internation Leadership Conferences
4. Would you be able to attend meetings?
   • __ during the day __ in the evening __none __not sure
5. What is the main reason you would not be able to attend?
   • ____________________________________________________
6. Would you like to be included in our members directory?
   • __ yes __ no
7. If yes, what information would you like to be included along with your name?
   • ____ address ____ home phone ____ work phone ____e-mail address
8. If the chapter provides pizza or subs, would you be willing to pay $2.00 to cover costs? __ yes __ no