International Member Reclaim Form

 DO NOT USE THIS FORM IF YOU HAVE BEEN PREVIOUSLY EXPELLED FROM THE FRATERNITY!
 ' * ' Denotes required fields.   If you need assistance, please contact the Membership Department at 404-284-5533 (USA) 

Member ID   *
             [ Also known as your 9-digit Control Number ]
  Last Chapter of Affiliation   *
                                             (listing by District-Chapter)
  Chapter of Initiation  *
                                  (listing by District-Chapter)
Initiation Date  *

Please provide current information below:
First Name  * Middle Name Last Name  *
Home Address  * Address Line 2  City  *
State  * Zip  * Country  *
Preferred Contact Number  * Email Address  *

UNIT PRICE

QUANTITY

TOTAL

International Member Dues
$300.00

1

$
Re-instatement Fee          
$3.00

 *

$
Late Fee          
$5.00

 *

$
Life Membership Fee          
$2,500.00

 *
[ Select quantity if you choose to apply ]

$
Partial Life Membership Fee          
$1,250.00

 *
[ Select quantity if you choose to apply ]
$

GRAND TOTAL    

$
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