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Theta Alpha Kappa Chapter Representative Membership Registration Form
Chapter representatives may complete this form for a free membership in the honor society. If you are replacing a colleague as chapter representative, please also complete the TAK change of chapter representative form. You will find a link to that other form when you finish this one.

Please note: TAK recognizes only one chapter representative at a time at each academic institution. This free membership opportunity is available only for the faculty member presently serving in this capacity.

If you are interested in pursuing honorary membership for someone who is not the chapter representative, this can be done through the Jernigan website with the standard induction fee.
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Email *
First Name (and middle initial, if desired) *
Last Name *
Address *
City *
State (two-letter postal abbreviation) *
ZIP code *
Phone number *
Email address you prefer for TAK correspondence (please retype even if already provided above; do not enter "same" or similar) *
The Present Semester (Fall or Spring) *
The Present Year (e.g., 2018) *
Academic Institution *
TAK Chapter Number *
TAK Chapter Greek Letters (spelled out, e.g., Alpha Beta Gamma) *
Thanks for completing this form. If you do not receive an email confirmation message shortly at the address you provided above, please contact us at If you have completed this form in connection with a transition of chapter representative leadership, please also complete TAK's change of chapter representative form at
A copy of your responses will be emailed to the address you provided.
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