Theta Alpha Kappa New Member Induction/Registration Form

Note:  Membership in TAK is by invitation only.  Submitting this form does not constitute membership in TAK.  Membership is granted after local-chapter induction and payment of induction fee.

New Member Name:  (Middle name or initial optional; include Jr., III or religious order after last name)
 
First Name:
Last Name:

Permanent  Mailing Address:

Street Address: City:
State: Zip Code:
Country: (if not USA) E-mail:

Institution and Induction Information:

College/University:
Chapter Code: Enter the 3-digit code provided by the chapter moderator (required field).
Membership Category:
Semester of Induction:
Year of Induction:
Expected Year of Graduation:
Chapter Moderator's
E-mail:		 (required field)

Please verify all information before clicking the "submit" button below.  A summary of the information you have entered will then be displayed.  Use your browser's print button to print this summary.  Return the summary to your local TAK chapter moderator along with the $25 induction fee (made out to Theta Alpha Kappa).  The moderator should send the summary and payment to the National Secretary:
 

    Dr. Betsy Bauman
    TAK, National Secretary
    St. Norbert College
    100 Grant Street
    De Pere, WI 54115

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