Five Star Chapter Excellence Program

University of Houston
ACTIVE MEMBER ROSTER FORM
*Form is due on September 1st for the Fall and February 1st for the Spring.*

THIS FORM MUST BE TYPED.

Semester (Fall/Spring): Year:

Council Affiliation:

Name of Greek Organization:

By my signature, I authorize the University of Houston Dean of Students and Campus Activities staff to share my
educational record with my fraternity or sorority in order to verify chapter eligibility and membership requirements and
for scholarship programs, advising, and for the purpose of chapter averaging. In addition, my discipline record may
be shared with my fraternity or sorority to verify that I comply with university policy as well as the standards of
membership and the values my organization espouses. I understand that this release will be in effect until I provide
written notification to the Campus Activities staff of any desired change.
Please note: State law requires that you be informed of the following:
1. With few exceptions, you are entitled on request to be informed about the information the University collects about you by use of this form.
2. Under sections 552.021 and 552.023 of the Government Code, you are entitled to receive and review the information; and
3. Under section 559.004 of the Government Code, you are entitled to have the University correct information about you that is incorrect

NAME PEOPLE SOFT # CONTACT # UH EMAIL

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Active Member Roster Form

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SUBMITTED BY: PAGE OF

For office use only

Date Submitted: Signature of Advisor:

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