Name:
Date:
(Last)
(First)
(Middle)
(Maiden)
Permanent Address:
(Street)
(City)
Phone:
(State)
(9-Digit Zip Code)
E-mail:
(Work)
(Home)
Former Chapter:
Occupation:
(Greek Name)
College/University:
Graduation Date:
Date of Active Initiation:
District: MW
(Fall/Spring)
NC
NE
SE
SW
W
(Year)
My check in the amount of $500 is enclosed.
Make checks payable to Kappa Kappa Psi
You may bill my VISA or MasterCard.
Name on Card:
Card #:
VISA
Exp. Date:
MasterCard