Chapter Name | ESG Initiation Request Form

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2	Please mail checks/money orders to Eta Sigma Gamma, National Office, P.O. Box 3919 Muncie, Indiana 47304
3	Chapter Name:			-------------------	-------------------------------	SHIP TO:
4	Date of Initiation:			-------------------	-------------------------------
5	Name of University:			-------------------	--------------------------------
6	Number of Initiates w/3 Yr Membership:			x $75.00
7	Number of Initiates w/1 Yr Membership:			x $50.00		Advisor or Chapter President
8	Number of Student Membership Renewals:			x $25.00		Home Address to prevent delays
9	Number of Honor Cords Needed:			x $20.00
10	Number of Scholarship Keys Needed:			x $25.00
11	Number of "New Logo" Lapel Pins Needed:			x 5.00
12	If desired,"New Logo" Chapter Tablerunner:			x 75.00
13	Total Amount Due:		----------------------------------	------------------	$ ______________
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15	Last Name	First Name	Email Address	Phone	Address	City	State	Zip
16	Faculty Sponsor(s)
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20	Chapter President
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22	Chapter Vice President
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24	Chapter Secretary
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26	Chapter Treasurer
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28	INITIATES:	*Place an astrik at the end of the last name to indicate 3 Yr Membership with Initiation
29	Last Name	First Name	Permanent Email Address	Major/Minor	Graduation Date	Cell Phone	State	Zip
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48	RENEWALS:
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