Chapter name, if wanted on certificate: _________________________________________________________________

Adviser: _________________________________________________ Phone Number: __________________________

Type carefully and please double space. Names will appear on the Membership certificates as they appear here. Indicate Faculty (F) or Honorary (H). Other names are assumed to be students.

Remit $20 per name. Make checks payable to Kappa Tau Alpha. (Vendor/ID#43-6037162) Do not send student checks.

Enclosed is a check for $___________ OR ___________ a University check to follow.