IB 364al

7/07

(ES)

DELTA OMICRON

INTERNATIONAL MUSIC FRATERNITY

Chapter Payment Form

Use this form for all chapter payments. Make checks to Delta Omicron Fraternity. All payments should be sent directly to the Executive Office: Julie H. Wright, Executive Secretary, 910 Church Street, Box 752, Jefferson City, TN 37760. Make 2 copies of this form. Send one to the Executive Secretary. Retain one copy in the chapter treasurer’s files.

CHAPTER ______________________________________________________________

NAME & CONTACT INFORMATION FOR REPORTING OFFICER:

NAME & OFFICE__________________________________________________

MAILING ADDRESS_______________________________________________

_________________________________________________________________

PHONE __________________________________________________________

EMAIL ADDRESS _________________________________________________

Payments: Please indicate the amount of payment for the specific fee or purchase.

National Fees	Amount Paid	Check #	Due Date
Annual National Dues ($30 per member) (Attach IB 368)			October 31
Optional Life Membership Dues ($300) (Attach IB 314)
Service Fee ($25.00)			October 31
Founders Day Pennies ($.98 per member)			April 1
Conference Investment ($200 per chapter)			April 1
Other	Amount Paid	Check #	Due Date
Star of Delta Omicron ($10.00 each) (Attach IB 378)			March or April
Supplies Order - IB 308
Jewelry Order – IB 336 (special orders)
	Amount Paid	Check #	Date send to Exec Secretary
TOTAL ENCLOSED:

Executive Secretary: Julie H. Wright, 910 Church St., Box 752 Jefferson City, TN 37760