Salutation: Dr. Mrs. Ms. Miss Mr.

* First Name:

Middle Name:

* Last Name:

* College:

* College Address (no PO boxes, please):

* City:


* State: * Zip:

* Country: Country Code:

Mailing Address (if different from college address; no PO boxes, please):

City:


State: Zip:

Country: Country Code:

* Phone Number with Area Code (include any extensions):

Fax Number with Area Code (include any extensions):

* E-mail Address:

* College Website:

* Which option best describes you?

Administrator
If so, please disclose position:

Faculty Member
If so, please disclose position:

Staff Member
If so, please disclose position:

Student

* Which of the following best describes your school's accreditation?

Fully accredited by Middle States Association of Colleges and Schools Fully accredited by New England Association of Schools and Colleges Fully accredited by North Central Association of Colleges and Schools Fully accredited by Northwest Association of Schools and Colleges Fully accredited by Southern Association of Colleges and Schools Fully accredited by Western Association of Schools and Colleges Candidate for full accreditation by one of the above accreditation agencies Fully accredited by Canadian government Candidate for full accreditation by Canadian government None of these

Which of the following do you offer?
Check all that apply.

Associate of Applied Science Degree

Associate of Arts Degree

Associate of Science Degree

Certificate - Canadian Degree

Diploma - Canadian Degree

University Transfer - Canadian Degree

None of these

* When would you like to charter?

Spring Summer Fall January February March April May June July August September October November December 2004 2005 2006 2007 2008 2009 2010

* How did you learn about Phi Theta Kappa?

Another chapter/college, name:

Faculty/friend contact, name:

Website, address:

Internet search, website address:

Publications, name:

College President, name:

College administration, name:

Personal experience - member, where:

Personal experience - advisor, where:

All-USA Academic Team mailing or All-State Academic Team Banquet

Conference, name:

Other, please explain:

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