OFFICIAL APPLICATION FOR INITIATION

This form, with the exception of the three required signatures, should BE TYPEWRITTEN or printed in ink. Please forward it before initiation together with the initiation fee ($70.00 which includes the badge fee) to the Executive Secretary. A copy of this form must be sent to the Province President before he or she can grant permission for the chapter to hold an initiation.

LEAVE BLANK

Date Report Received

Prospective Member Fee Paid

Initiation Fee Paid

Badge Ordered

National Number

Computer Entry

File Cards Made

Certificate Sent

Life Member Number

Admission into________________________________________ Chapter

This is to certify that:

Name: _____________________________________________________

First Middle (Maiden) Last Spouse’s

will be duly initiated on _______________________________________

Date

as a ______________________________________ Member, and will be

Collegiate/Faculty/Professional

assigned No. ________________ in Chapter Membership Record Book.

Place of Birth ______________________ Date of Birth _____________

Home Address: _________________________________________________________________

Number and Street

______________________________________________________________________________

City, State, and Zip Code

School Address: ________________________________________________________________

Parent’s or Guardian’s Name ______________________________________________________

Do you have any relatives who are members of Delta Omicron? __________

Name _________________________________________________________________________

First (Maiden) Last Chapter Relationship

What is your Major Study? ________________________________________________________

What are your Minor Studies? _____________________________________________________

Equivalent or Music Minor: List Classes ____________________________________________

Faculty approval of GPA of the previous term in music courses and courses outside subjects according to the National BYLAWS: YES _____________ NO ______________

In what year of work are you classified? _____________________________________________

What other institutions of learning have you attended? __________________________________

Name and kind of other National Fraternities or Sororities in which you hold membership ______

______________________________________________________________________________

The above data is accurate and complete to the Fraternally submitted,

best of my knowledge.

____________________________

Chapter First Vice President sign here

________________________________________ ____________________________

Initiate must sign full name legibly Chapter Adviser countersign here