Phi Theta Kappa – Tau Phi Chapter

Membership Information Form

(Please note: this form may be filled out anytime and returned to Nancy Woods or you can fill it out the day of our initiation ceremony!)

Name: ________________________________ Date: _________

New inductee Alumni Current Member

Telephone Number(s): ________________________________

Contact Information:

E-Mail at _________________________

Regular Mail _______________________

_______________________

Are you a regular e-mail user?

____ yes I check my e-mail regularly

____ no I rarely use e-mail

What times are convenient for PTK meetings? Please note: we would appreciate it if you would fill in all convenient times so that we can best plan our meetings around your schedule. Please put an X in all of the boxes that fit your schedule:

	Monday	Tuesday	Wednesday	Thursday	Friday
7:30-8 am
10-11 am
11-noon
Noon–1
2:30-3:30
3-4 pm

Are there other times, not listed above, that better suit your schedule? [i.e., Weekends, nights, etc.]

As a member of Phi Theta Kappa, what are some of the things that you hope PTK can do for you?

What would you be interested in? Please check all that apply:

___ Leadership ___ Accounting

___ Fellowship ___ Volunteering

___ Advertisement ___ Chairing a committee

___ Journalism ___ Helping a committee

___ Fundraising ___ Being an officer for PTK

___ Web page design ___ Other: _______________

What is your major at DMACC?

Do you have any long-range areas of specialization?

What is your long-range educational goal?

__2-year degree __4-year degree __beyond 4-year degree __uncertain

(AA, AS) (BS, BA) (PhD)

Will you return to Boone Campus DMACC next semester?

Do you plan to graduate from DMACC? If so, when?

Do you intend to transfer to a university? If so, where?

Please tell us anything about yourself—your ambitions, educational goals, or anything you wish to share! We want to know more about you!