Date:________________________

1. Requesting reactivation of your membership *
a. ____________   National dues one year, $15
b. ____________   Active-for-Life Membership (a single $200 payment covers all future
National dues. You will receive a special life member certificate and automobile decal).

2. ____________________    Requesting transfer of membership to another chapter.
List new chapter here:

_____________________________________________________________
 
 
 
 

_____________________________________________________________________________________________________
City State Zip Code
 
 

_____________________________________________________________________________________________________
Name under which you were initiated if change has occurred
 
 
 

_____________________________________________________________________________________________________
Name of original chapter of initiation
 
 

Date of Initiation_______________________________________________________________________________________

* Note:   Requests for Reactivation of Membership should be accompanied by a check
for $15 to cover National Dues ($200 for Life Membership) and $10_______
chapter dues for one year.

Return to: John W. Warren, Executive Director
 The Honor Society of Phi Kappa Phi
 P.O. Box 16000 - Louisiana State University
 Baton Rouge, LA 70893
 
 
D-5, 5/96