MEMBERSHIP REGISTRATION FORM

LAST NAME FIRST NAME MIDDLE NAME SUFFIX PREFIX NICKNAME

CHAPTER SCHOOL & LOCATION POSITION & YEAR

ATTACH PASSPORT SIZE
BATCH NAME BAPTISMAL NAME BATCH YEAR RITUAL DATE (MM/DD/YYYY) PHOTO UNRETOUCHED TAKEN
WITHIN LAST SIX NMONTHS
WITHOUT HAT OR GLASSES
DATE OF LAST REGISTRATION
RESIDENT BROTHER RESIDENT SISTER ALUMNUS ALUMNA LIFE ASSOCIATE
(MM/DD/YYYY)
ADMINISTRATIVE REGION SECTION

AGE BIRTH DATE (MM/DD/YYYY) BIRTHPLACE BLOOD TYPE

HOMETOWN ADDRESS ZIP CODE TELEPHONE FAX

MAILING ADDRESS ZIP CODE TELEPHONE FAX

E-MAIL ADDRESS WEB SITE CELL PHONE

RAD I:
COURSES TAKEN SCHOOL YEAR

CHAPTER:

ID NUMBER:
PROFESSION/TRADE/OCCUPATION & COMPANY POSITION
RAD II:
BUSINESS ADDRESS ZIP CODE TELEPHONE FAX

ALUMNI ASSOCIATION POSITION HELD YEAR

DATE FILED:
ORGANIZATION (OTHER THAN APO) POSITION HELD YEAR

By: ________________
C H A PTER P OSITION H E LD; G C/G LC & P C /PLC ONLY (C HAP TER : P O SITION : S C HOOL YE AR)

C H A PTER &/O R A LU MNI ASSOCIATION ORGANIZE D (C HAPTER/AA NO. : YE A R) RESULTS OF

VERIFICATION:

INSURANCE BENIFICIARY RELATIONSHIP ____________________

DB Record No.
COMPLETE ADDRESS TELEPHONE
____________________
Verifier
MEMBERSHIP RE-AFFIRMATION PLEDGE
O N M Y OATH, I hereby affirm that I shall abide by our N ational Code of By -Laws; comply with all lawful orders of our duly constituted leadership; maintain my ____________________
good standing by fulfilling the duties of membership; endeavor to realize the ideals of the o rganization by excelling in my chosen field, by extending a hand of ID No.
friendship to all regardless of race, religion, social class, or political ideology, and by unselfishly giving my time and en ergy in pursuing a program of service to our
fraternity and sorority, to the students and university, to the youth and community, and to the nation as a fully participating citizen. I shal l, in all my dealings,
uphold the dignity of A lpha P hi O mega by good example through thoughts, w ords, and deeds. DATE FEE PAID:
A ll these I do promise w ithout mental reserv ation or purpose of ev asion. S O , H E LP M E , G O D.

Amount:
S ignature: Date:
FOR NEW APPLICATIONS & SPECIAL CASES ONLY ID NO. : VALIDITY REMARKS & SIGNATURE
ENDORSEMENTS (GC/GLC OR PC/PLC PLEDGE PERIOD) O.R. No.:
:
OTHER (NAME : POSITION : SCHOOL YEAR)
: Validity:
SECTION CHAIR
: 2015-2017 Control No.:
REGIONAL DIECTOR FOR COLLEGIATE
: 2015-2017
REGIONAL DIRECTOR
: 2015-2017 ____________________
Received by
COMMISSION ON MEMBERSHIP REGIONAL REPRESENTATIVE
: 2015-2017
NATIONAL EXECUTIVE DIRECTOR ____________________
ID No.
REINALD D. RELOVA 0 8 4 48 : 2015-2017
FOR VERIFICATION (ALL NEW APPLICATIONS AND THOSE FALLING UNDER SPECIAL CASES)
GC/GLC AT DATE OF JOINING MY IDENTIFYING MARKS OR UNUSUAL FEATURES DATE ENCODED:

PC/PLC AT DATE OF JOINING

BATCHMATES ____________________
Encoder

TOTAL BATCHMATES ____________________

OTHER REFERENCES (FROM SAME CHAPTER) ADDRESS/PHONE ID No.