Delta of Missouri Alumni Association
Member Biography
First Name:__________________________
Middle Initial:_______ Last Name:_____________________________
Address: _____________________________________________________________________________________
City: _____________________________________________
State: ___________ Zip: _______________________
Home Phone: (_______) _______-_________
Work Phone: (_______) _______-_________
ext: ______________
Cell Phone: (_______) _______-__________
E-mail: __________________________________________________
SS# (last 4 digits are required): ________-______-__________
Birthdate: _________________________________
Employer:
____________________________________________________________________________________
Position Held: _________________________________________________________________________________
Transferring to/Graduated from
Senior Institution: ____________________________________________________
Major field
of study/Degree(s) Earned: _____________________________________________________________
Year inducted into Phi Theta Kappa:
__________________ Chapter: ___________________________________
Associate Degree(s) or
Certificate(s) earned at East Central College (include year): __________________________
_____________________________________________________________________________________________
Degree(s) or Certificate(s) earned
at any other college/university (include year): _____________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Office(s) or Committee Position(s)
held in Phi Theta Kappa (include year): _________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Awards and Honors:_____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Other organizational involvement or
memberships (academic, community, or professional): ___________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Special talents or
abilities:________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Suggestions for alumni projects and
participation:_____________________________________________________
_____________________________________________________________________________________________
Check here if you do not want your address and home phone
number to be published:
For membership in Delta of MO, please send this form
and a check (made payable to Delta of
Missouri Alumni Association) in the amount of $20 for annual dues to
Delta’s Secretary/Treasurer: Amy Pope, 1516
E 6th St, Washington, MO 63090. To obtain an official Alumni
Membership Certificate from International Headquarters, please include an
additional $5.