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.