EmailMe Form - New Inductee Materials Order Form-Current Chapter

College or University *

Chapter Name: *

Program Name *

Chapter Advisor

First Last

Chapter Advisor: Are you a current member of Chi Alpha Epsilon? *

Yes

No

If yes, when were you inducted? If no, put N/A. *

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Shipping Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Please attach the XAE Induction Log to this order form. If you do not have an updated copy of the log, please send an email to xaenhsmembership@gmail.com and one will be provided to you.

For verification, please attach a copy of prospective members transcripts for GPA verification. The easiest way to do this is by scanning the transcripts into one document. If you need help with this process, please email Tekora Scruggs at xaenhsmembership@gmail.com. Please put in the subject line "Transcripts for (the name of your institution)"

GPA Verification Form (this form can be found on the Chi Alpha Epsilon website, under the Members Only section "Forms".)

This is a required form. *

Each inductee requires an Individual Induction package. Options listed below.

Individual Induction package with certificate, cord, key pin, and decal: $65.00
Total Requested:

Sub-Total

$ Dollars . Cents

Grand Total

$ Dollars . Cents

Please include 9% for shipping and handling. An invoice will be emailed to the email address provided above.

Date of Induction Ceremony *

MM / DD / YYYY