PHI THETA KAPPA OMICRON BETA CHAPTER
MEMBERSHIP APPLICATION
REMEMBER TO COMPLETE EVERYTHING, INCOMPLETE
PACKETS WILL NOT BE PROCESSED:
Please
indicate the type of membership you prefer: All membership types
include the basic benefits of joining
Double click the box to change it to a
check mark
Enhanced Membership
– You would like to be informed via e-mail about chapter activities and
participate in the Enhanced Membership Program. There is no obligation to participate and no additional cost
to enroll.
Regular Membership –
You prefer not to be informed and have no interest in being an active chapter member.
Please PRINT or TYPE the information below. If there is a mistake on your membership certificate from the International Headquarters, you will have to pay additional money to have your certificate returned and printed correctly.
Social Security
Number
OR Student ID Number
TYPE your name, as you would like it to appear on your
certificate)
First Name
Middle Name
Last Name
Permanent
NOTE: Providing this information will
result in e-mail correspondence from PTK International regarding updates, special
opportunities & scholarship information.
Semester hours you
have accumulated at MCC
GPA
A minimum of
12 credit hours at MCC (courses under the 100 level do not apply) and a cumulative GPA of 3.5 or better.
Campus: (Select one) Dobson
& Southern
OR Red Mountain
OPTIONAL INFORMATION: Phi
Theta Kappa receives numerous requests for the following information from
universities and foundations. The
ability to supply this information will benefit both our scholarship programs
and grant applications.
Race: American
Indian
African-American
Caucasian
Hispanic
Asian/Pacific Islander
Other
Sex: Male
Female
Date
of Birth: (MM/DD)
/
IMPORTANT: Graduation/Transfer Data and Major MUST be entered to be eligible for scholarship benefits
Last semester/year
you expect to attend MCC: Month
Year
(please fill in both dates)
Major field of study at MCC: (check one)
Undecided
Accounting
Agricultural Science
Architecture/Drafting
Art
Aviation
Biology
Business
Chemistry
Civil Engineering
Communication
Computer Science
Counseling
Criminal Justice
Dental
Economics
Education
Electrical Engineering
Electronics
English
Environmental Studies
Fashion
Finance
General Science
Health
History
Information Tech.
Journalism
Languages
Legal
Liberal Arts
Management
Marketing
Mathematics
Mechanical Engineering
Medical Tech.
Nursing
Organizational Leadership
Pharmacy
Physics
Political Science
Law
Pre-Medicine
Psychology
Public Relations
Religion
Social Sciences
Theater
Veterinary Medicine
Other
MEMBERSHIP
AUTHORIZATION:
By completing this form I certify the
following: I have met all membership
eligibility requirements for Phi Theta Kappa, and have been extended an
invitation for membership in my local chapter. I believe in and support the purpose of the Society as stated in the Phi
Theta Kappa Constitution, adhere to the moral standards of the Society, and
currently enjoy the full rights of citizenship, freedom, and privileges of my
country (International students attending college on a United States student
visa and who possess full rights of citizenship of their country are eligible
for membership.) I understand that there
is a required GPA for maintaining membership in Phi Theta Kappa and agree to
notify my chapter advisor immediately if at any time I fail to maintain my
chapter’s maintenance GPA. Therefore, I
solemnly promise to uphold the standards of Phi Theta Kappa, and to make this
object and aim foremost in my mind, and I do solemnly pledge allegiance to my
fellow members and promise to aid them in all worthy endeavors.
Signature:______________________________________________________ Date: ________________________________
OFFICE USE:
Chapter
Membership Form ____ Unofficial Transcript ____ Check, Money Order, Deposit
Slip # ________ Date _________
Return completed
forms to: MCC Center for Service-Learning: 1833 W. Southern Avenue, Mesa, AZ 85202 (480) 461-7393