Charter Member Information Profile

*Chapter: —Please choose an option—University of Maryland College ParkWest Virginia State University

*First Name:

Middle Name:

*Last Name:

*Email Address:

*Address:

Apt:

*City:

*State: [stateselect]

*Zip:

*Major:

*Overall GPA:

*Credit Hrs Completed:

*Anticipated Graduation Month/Year:

*Name as you want it to appear on your certificate:

*Please choose one: KeyLapel Pin with Magnetic Back

Please type in what you see to the right:

*I CONSENT TO ALLOW THE NATIONAL OFFICE TO VERIFY MY GPA. THE NATIONAL OFFICE WILL NOT REQUEST A COPY OF YOUR TRANSCRIPTS, ONLY CONFIRM YOUR GPA.

*University Student ID: