University (enter name of university):

Initiation Date (format mm/dd/yyyy):

Chapter name (enter name of chapter - e.g., Frank Luther Mott Chapter):

Chapter Adviser (name of chapter advisor):

Phone Number (format XXX-XXX-XXXX):

Chapter Advisor email(format = email@school.edu):

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

Provide below the name and address of the person to whom the shipment of certificates should be sent.
(format: Name, Address, City, State, Zipcode)

If you wish to order Top Scholar awards, please enter the following:

Top Undergraduate Student (if more than one, add $35 for each additional name)

Top Graduate Student (if more than one, add $35 for each additional name)

Number of Honor Cords requested (@$6): Number of KTA Medals requested (@$8):

The initiation fee is $30 per person. Number of new initiates:

Make checks payable to Kappa Tau Alpha. (Fed. ID #43-6037162). Student checks cannot be accepted.

A University check for $ will follow via US Mail.