Alpha Delta Gamma National Fraternity
Member Information Form
Please complete all parts of this form. Failure to do so may result in delayed membership
activation, incorrect billings, and delayed notification of important information and events.
Please provide permanent information in all cases; dorm room, apartment, or other temporary
housing information is not to be used.
First Middle Last
City: State: Zip Code:
Country: Email Address:
(Only complete if not a U.S. citizen) (Permanent – not student/college account)
Permanent Phone: ( ) Mobile Phone: ( )
Date of Birth: / /
Month Day Year
Chapter: The undersigned represents and warrants that the
information provided is true and complete and will remain
so until written notice of change is given to the National
Office by the undersigned. The undersigned agrees to pay
Pledge Semester: Fall / Spring all membership dues, insurance, and any other payments set
(circle one) Year forth in the National Constitution and By-laws of Alpha
Delta Gamma National Fraternity, both now and in the
Date of Induction: / / future. Furthermore, the undersigned agrees to pay the
Month Day Year aforementioned payments in a timely manner, according to
the guidelines set forth in the National Constitution and By-
laws of Alpha Delta Gamma National Fraternity.
If you wish to charge our national dues to a credit
card, Please visit our national website at
Signature (Member) Date
To pay in other form, please contact the Vice
President of Finance for details on how to pay.
Witness (Chapter President or Ombudsman) Date