| NOTE:This form should only be used in an emergency situation. Contact the PKD office for an official form (Membership form = gray card). Class: Active ________ Inactive ________ Honorary ________ Orders: Active Undergraduate ________ Instruction ________ Active Alumni ________ Degrees: Degree of Proficiency ________ Degree of Special Distinction ________ Degree of Highest Distinction ________ Please check the appropriate line. -------------------------------------------------------------------------------- PI KAPPA DELTA Application for Membership Office use only N ________ R ________ Date ________________ 20 ________ Miss CIRCLE Mrs. _____________________________________ Grad. Year ________________ ONE Mr. Name, print or type Dr. COLLEGE/UNIV.:________________________________________________ ADDRESS:________________________________________ CITY:___________________________ STATE:________ CHAPTER NAME: _________________________________ PROVINCE: ________________________ CURRENT MAILING ADDRESS CURRENT PHONE: (____)____________ STREET/RT/BOX/SCHOOL: ___________________________________________________________ CITY/STATE: _________________________________________________ ZIP: ________________ PERMANENT HOME ADDRESS: HOME PHONE: (____)____________ STREET/RT/BOX/SCHOOL: ___________________________________________________________ CITY/STATE: _________________________________________________ ZIP: ________________ CHAPTER APPROVAL ________________________________ ______________________________ Chapter Pres. Signature Sponsor Signature -------------------------------------------------------------------------------- Contact the PKD office for an official form (Membership form = gray card). Pi Kappa Delta P O Box 38 Ripon, WI 54971 (920) 748-7533 (920) 748-9478 FAX nflpikappa@nflonline.org |