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Member Application
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Name of student ____________________________________________________________________
Address ___________________________________________________________________________
Social Security No. __________________________________________________________________
Telephone No. _____________________________________________________________________
Overall GPA ___________________ Total Credit Hours Completed ___________________________
| Psychology Courses Taken | Grade | Credit |
|---|---|---|
Participation in Psychology Club (3 Activities) or 10 hours of Community Service: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Psychology courses in progress this semester: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Statement of Release I hereby authorize the Psi Beta National Council to inspect and verify my college records for the sole purpose of determining my eligibility for becoming a member of Psi Beta. I verify that the information provided above is accurate to my knowledge.
Signature____________________________________________ Date ________________
Return to Dr. Cheney with $50.00 membership fee (check should be made
out to Dr. L.W. Cheney).
If there are any questions, please call
825-2222 or 825-2258.
