Note: Provisional Memberships are ONLY for Freshmen in their first semester at their university.

    *Chapter:

    *First Name:

    Middle Name:

    *Last Name:

    *Phone Number:

    *Email Address:

    CURRENT ADDRESS:

    *Address:

    Apt/Unit (if applicable):

    *City:

    *State:

    *Zip:

    PERMANENT ADDRESS:

    *Address:

    Apt/Unit (if applicable):

    *City:

    *State:

    *Zip:

    Please type in what you see to the right: captcha