Membership Revocation Form

Please read this important introduction to the Membership Revocation Form before proceeding.

Important note: This form can only be submitted by an advisor. The advisor's name and e-mail address on this form MUST match that of the advisor on Headquarters records for the chapter, or the revocation will not be completed.

All answers on this form are required for submission - it must be completed in full before it can be submitted.

The following individual has failed to maintain the academic standards necessary to continue membership in Phi Theta Kappa.

Member's Name:

Member Identification:

College:

Chapter:

Date of Induction:

Member's Name When Inducted:

Chapter Advisor's Name:

E-mail of Chapter Advisor:

If the information on this on-line form is complete and ready to be sent to Headquarters, press Submit. If you would like to clear the form and start over, or wish to complete the form at a later date, press Reset.