Mortar Board Application Sheet
Full Name ______________________________________________________________
Student ID Number_________________ Email_______________ Phone____________
Campus Address (include zip) ______________________________________________
Parent, Spouse,or Guardian’s Name___________________________________________
Grade Point Average_______________________ Graduation Date__________________
I hereby declare that all the information I am providing on this application is complete and accurate to
the best of my knowledge, and I hereby authorize the Selections Committee to verify this information.
If selected I agree to pay the $100 membership fee, and be an ACTIVE member of Mortar
Board. (One full or two partial scholarships may be granted to selected students who need assistance.)
Email should be submitted to Will Pearson at email@example.com or Suzanne Phillips at
firstname.lastname@example.org or in person at Dean of Students Office, Indiana Memorial Union, M-088, IU-
**DUE by 5pm on February 1, 2012**
Please TYPE answers to the following questions on a separate sheet(s). Please include your social
security/student ID number, and your name on the top of each sheet/ Keep in mind that Mortar Board
does NOT discriminate on the basis of race, gender, religion, sexual orientation, ethnic origin or
**Please limit your response to two typed pages.**
1. GPA, Major(s), and Minor(s)
2. Please LIST, describe and date significant academic honors, awards or achievements you have
received during your college studies.
3. Please LIST and describe your chosen field(s) of study and your future plans.
4. Please LIST and describe your significant extracurricular activities on campus, within the
community, or as employment. For each activity please include the following information:
a. The name of the organization
b. The nature of your involvement and a description of the responsibilities of any
office you held.
c. The duration of your involvement in the activity, and
d. The average ongoing time commitment you had with the activity
5. What can you contribute to Mortar Board as a member or an officer? Please include activities
or programs you would like to see implemented.
6. The Selections Committee recognizes that many Mortar Board applicants are highly motivated
individuals who are generous in their time commitments to various activities and who normally
excel at most of their endeavors. With this in mind, is there anything special and unique about
you that should be taken in to account when the Selections Committee reviews your