Application for Psychology Club

Membership
Personal Information
Name:_____________________________________ PS#:________________________
Mailing Address:_________________________________________________________
City:___________________________ State:_________________ Zip:_____________
Phone:____________________________ Email:_______________________________
Please check the box below if you authorize Psi Chi to add your name & email address to
the chapter directory. All other information will remain confidential.
Academic Information
Please check one:
Classification:

Freshman_____ Sophomore___ Junior_____ Senior_____

Full Time Student______________

Part Time Student_________________

Estimated Graduation Date (month/year):________________________________

Major:_____________________________
Minor:_____________________________
Please write the Psychology courses you have taken to date & only indicate the grades
earned here at the University of Houston. If the Psychology course was taken at a
different institution, please indicate with a T for transfer.
Course (Name & Number)
Grade Received
Credit Hours
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_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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__________
Estimated Cumulative GPA_____________ Estimated Psychology GPA___________
All academic information will be submitted for verification. If you are unsure about a
grade or GPA, you may leave it blank.
In a few words, please explain why you would like to join this organization.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
______

I hereby authorize Psi Chi to review my college records for the sole purpose of
determining my eligibility for becoming a member of Psychology Club. My
signature confirms that all the information provided is true to the best of my
knowledge.
Signature_____________________________________Date____________________
Please return this form to Room 105 Heyne, or the Psi Chi box located within the
Graduate Student boxes in the Heyne Bldg.
For Office Use Only:
Approved by:_________________________________Date:______________________
Chapter Dues_________________________________