College:

Chapter:

Date on which officer terms expire:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Name of Chapter Officer:

Position of Chapter Officer (ie, Vice-President):

Mailing Address:

City:


State:       Zip:

Phone with Area Code:


Email Address:

Information Submitted By:

Date Submitted:

The officers reported above will receive periodic updates from the Phi Theta Kappa Michigan Region regarding important events, deadlines, and news of interest.

If the information on this on-line form is complete and ready to be sent to the Regional Executive Board, press Submit. If you would like to clear the form and start over, or wish to complete the form at a later date, press Reset.