Phi Theta Kappa Membership Application – Upsilon Eta Chapter Completion of this application is a requirement of membership. Please return this form to a chapter officer/advisor upon completion along with an unofficial copy of your transcript. Please PRINT neatly and legibly. First Name: _____________________ Last Name: _________________________ Date of Birth: _________________ Address: ________________________________________________________________________________________ City: _________________________ State: _________ Zip Code: _________ FSCJ User ID: ____________________ Preferred Telephone: _________________ Preferred Email : _____________________________________________ (This is how receive your member number. Check your spam.)
Major: _________________________________ Anticipated Graduation Date: ______________________________
To become a member, an individual must meet all membership eligibility requirements for Phi Theta Kappa according to its Constitution and Bylaws. Invitation to membership is extended by the local chapter, Upsilon Eta. After becoming a member, an individual is required to maintain the minimum GPA for membership as established by the local chapter and must notify the chapter advisor immediately if at any time their cumulative GPA falls below that standard. Failure to provide notification may result in membership automatically being revoked. A member is given one term to raise his/her cumulative GPA to minimum standards. A person currently incarcerated is ineligible for membership. An individual convicted of a felony or any crime whose potential sentence is greater than one year may be considered for membership three years following completion of all conditions of sentencing, including probation. I believe in and support the purpose of the Society, meet eligibility standards for membership as stated in the Phi Theta Kappa Constitution and adhere to the moral standards of the Society. Therefore, I solemnly promise to uphold the standards of Phi Theta Kappa, and to keep this object and aim in mind, and I do solemnly pledge allegiance to my fellow members and promise to aid them in all worthy endeavors.
_____________________________________________________________ Signature
___________________________________ Date
Advisor/Staff Use Only
Date Paid: _________________________________________
Effective Term: ________________________________________
Payment Method: __________________________________
Entered in PAM: _______________________________________
Receipt #: _________________________________________
PTK Designator Added: __________________________________
GPA: _____________________________________________
Transcript Notation Request Date: _________________________
Comments: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Phi Theta Kappa, Florida State College – Kent, 3939 Roosevelt Blvd. G-150, Jacksonville, FL 32205;
[email protected]; (904) 381-3440
