Instructions Please refer to the International Bylaws, Article III

JA/MX Form H-103 Revised-14

DO NOT STAPLE CHECK TO FORM

ALPHA DELTA KAPPA

1. Must be completed in full by applicant. 2. Return to chapter membership chairman with membership and badge fees. 3. Chapter membership chairman sends form with fees to International Headquarters prior to initiation. 4. Send Report of Initiation (Form H-133) to Headquarters immediately after initiation.

International Honorary Organization for Women Educators

MEMBERSHIP APPLICATION

Nation

Chapter Name

MEMBERSHIP APPLICATION: I Hereby Wish to Petition for Membership in Alpha Delta Kappa. Applicants MUST be under contract in education to qualify for membership. Name Complete Mailing Address as it should appear on Mailing Label:

Place of Employment Business Phone Number (

)

Home Phone Number (

Business E-Mail

)

Home E-mail ENTIRE SECTION MUST BE COMPLETED — PLEASE CHECK ONLY ONE BOX IN EACH LINE:

Is currently under contract in education?  Yes  No Has been in the education profession two full years or more?  Yes  No Professional/Job Title: Position:  (1) Teacher

 (2) Administrator

Level:  (4) Elementary

 (5) Secondary

Degree(s) in Education Received:  Bachelor’s

 (3) Other  (6) College/University

 Master’s

 Doctorate

 (7) Other  Other

Certification:

 Yes

 No

MEMBERSHIP ETHICS: I submit this application with the knowledge that Alpha Delta Kappa membership is an honor. I will accept the responsibilities and obligations of membership and regularly attend all meetings. Signature of Applicant

Date of Birth

MEMBERSHIP FEE AND BADGE ORDER: Once your initiation is reported to Headquarters, you will receive your New Member Packet, including your member Handbook and current International Bylaws. Your subscription to our magazine, the (MO/DAY/YR) KAPPAN will also begin. (Please send one check for total due, payable to Alpha Delta Kappa.) FEE FEES PAID 1. One-Time Membership Application Fee (Required, nonrefundable) $5.00 (U.S. funds only) $5.00 2. Membership Badge (Required): A. Item #5: International Membership Badge $21.00 (U.S. funds only) B. Item #00: Official Badge With Seven Jeweler-Set Pearls With K Guard & Chain $42.00 (U.S. funds only) C. Item #3: Gold-Filled Membership Badge and K Guard With Magnetic Closure (Pacemaker users should not wear magnets) $48.00 (U.S. funds only) 3. Postage (Please use the chart below. U.S. funds only.) POSTAGE & HANDLING CHART 1-2 badges...........$6.50 total 3-5 badges...........$8.25 total 6 or more badges...$10 total Annual International dues will be payable in January of the calendar year following your initiation. TOTAL NAME OF MEMBER SPONSORING NEW MEMBER

Nation and Chapter

Badges are shipped to chapter membership chairman. Chapter membership chairman’s name Chapter membership chairman’s complete mailing address Telephone ( Current date

)

Anticipated date of initiation SEND TO INTERNATIONAL HEADQUARTERS Alpha Delta Kappa, 1615 W. 92nd St., Kansas City, Missouri 64114-3210, USA • (816) 363-5525 • (800) 247-2311 Additional forms may be printed from the Alpha Delta Kappa International Website at www.alphadeltakappa.org. Please do not fill out a jewelry order form for your membership badge. THIS APPLICATION WILL AUTOMATICALLY ORDER THE BADGE. MO/DAY/YR