PHI DELTA KAPPA INTERNATIONAL
                                       ASSOCIATE MEMBERSHIP APPLICATION
                                       Why a membership in PDK? Review the benefits; you’ll be convinced of the value of this global organization of
                                       quality educators.
                                       Because we are your quality source for research.                       Because our website hosts a comprehensive
                                       Meeting your need for the latest in research, theory,                  searchable archives database available 24 hours a
                                       and practice, PDK brings you the Phi Delta Kappan (in                  day. With a PDK membership, you have access to a
Phi Delta Kappa International          paper copy, audio, or electronic version), the most                    broad publication archive AND 38 years of results from
                                       referenced educational journal.                                        the Annual PDK/Gallup Polls of the Public’s Attitudes
408 N. Union, P.O. Box 789
                                       Because we provide connection. You can share ex-                       Toward the Public Schools. Why pay a fee to download
Bloomington, IN 47402-0789                                                                                    one article at a time?
Phone 800-766-1156 or                  periences with other educators through local chapter
                                       networks (optional); regionally and globally, we provide               Because everyone wants to save money. Our schol-
       812-339-1156                    forums for gathering national leaders at the annual                    arships and fellowships could be an economic benefit
Fax 812-339-0018                       summit and at workshops.                                               you’ve not considered, and don’t forget the consider-                                                                                               able discounts on publications and professional devel-
                                       Because security in all areas is key to success. There                 is peace of mind in taking care of the basics; we can                  opment registration costs.
                                       help with that. You can benefit from group rates on pro-
                                       fessional liability, health, life, and auto insurance plans.

Associate membership is available to parents, civic leaders, or government officials who support the mission and purposes of Phi Delta Kappa Inter-
national and who want to stay informed about issues in education. Note as well that graduate students who are career changers are welcomed into
PDK under this membership category.The purpose of Phi Delta Kappa International is to promote quality education, in particular publicly supported edu-
cation, as essential to the development and maintenance of a democratic way of life. Completing this application indicates your support of this purpose.
(Please print clearly)

                               (Last)                                                     (First)                                        (Middle)

PREFERRED FIRST NAME                                                                      PREFERRED E-MAIL ADDRESS

HOME ADDRESS                                                                              WORK ADDRESS

STREET / P.O. BOX                                                                         EMPLOYER (no acronyms please)

CITY                                                                                      STREET / P.O. BOX

STATE/PROVINCE                                                 ZIP/POSTAL CODE            CITY                                      STATE/PROVINCE      ZIP/POSTAL CODE

HOME PHONE                                                                                WORK PHONE

                                                                             ABOUT YOU

Date of Birth _______________________                       Male      Female

Eligibility (check one)
    ___ parent                             ___ school board                                                           ___ career changer (if you have returned to
    ___ legislator                         ___ PTA/PTO member                                                             school to become certified as a teacher for
    ___ civic leader                       ___ business individual                                                        the first time in your career, you qualify for
    ___ goverment official                 ___ other (please specify)________________________________                     membership at 1/2 the regular associate
                                                                                                                          member dues)

                                                             REFERRAL INFORMATION (optional)

                          Please enter the name and ID number of the member who referred you to Phi Delta Kappa.

Member Name (please print) _______________________________________________________ Member ID number

                                                                        MEMBER SURVEY

                                                  What prompted you to join PDK? (Check all that apply.)
    1      Colleague recommended                           7     Training/workshop                             13       Affiliation with a professional associ-
    2      Supervisor recommended                          8     Advertisement                                          ation
    3      Professor recommended                           9     Promotional brochure                          14       Former member
    4      KAPPAN journal                                 10     Website/ Internet                             15       Other: __________________________
                                                                                                                                       (please specify)
    5      PDK/Gallup Poll                                11     Conference
    6      Publications/products                          12     Direct mail
                                                 What are your membership needs? (Check all that apply.)
    1      Resources/information                           4     Résumé development                                7    Scholarships/awards
    2      Networking                                      5     Local chapter activities                          8    Other: __________________________
    3      Discounts on products/services                  6     Volunteer leadership opportunities                                     (please specify)

                                                                AFFILIATION AND PAYMENT
OPTION #1: CHAPTER-AFFILIATED MEMBERSHIP                                             PAYMENT
To locate a chapter name, number, and dues amount, please visit our                  Membership is for one year from the date payment is received at the
website at                                  International Office.
        I want to affiliate with the following chapter:                                  ANNUAL Auto Renewal. For uninterrupted service, PDK
                                                                                         will bill your credit card at the current renewal rate once
_________________________________________________                                        a year on your anniversary date. Notify PDK to change.
                    (enter chapter name and number)
                                                                                         MONTHLY Auto Renewal. For uninterrupted service, PDK
                                                                                         will bill your credit card at the current renewal rate
Fees:         International Dues                      $      70.00  1
                                                                                         monthly based on your anniversary date. Notify PDK to
              Processing Fee                          $       5.002                      change.
              Chapter Dues3                           $ __________                       STANDARD One-Year Renewal. Pay with credit card,
              (enter chapter dues amount)
                                                                                         check, or money order in U.S. dollars.
              Total Fee                               $ __________
                                                      (U.S. DOLLARS)                     Check payable to Phi Delta Kappa International in the
                                                                                         amount of $ ________________ is attached.
OPTION #2: MEMBERSHIP WITHOUT CHAPTER AFFILIATION                                    Please bill my           VISA                 MasterCard
        I do not want to affiliate with a local chapter at this time.                                         Discover             American Express
        (Please note: Chapter affiliation is available to members at any time
        upon request.)                                                               Credit Card
Fees:                                                 $        85.004
                                                       (U.S. DOLLARS)                Expiration Date           /
If you currently have a subscription to the Phi Delta Kappan journal,
please enter your account number here:
K______________. Any remaining balance will be refunded after your
                                                                                     Cardholder’s Name (please print)
membership application has been processed.
 Career changers pay $35.00 for international dues with a chapter affiliation.
 Career changers pay a $2.50 processing fee.                                         Signature Required
 Career changers pay only one-half chapter dues.
 Without a chapter affiliation, career changers pay $42.50 for one year of
    direct membership.                                                               Daytime Telephone                                            Date

Please return this form to the PDK Representative listed below:
        Phi Delta Kappa International
        P.O. Box 789
        Bloomington, IN 47402-0789
        (Chapters place your labels here)

Applicant’s Signature                                                      Date

Chapter Representative’s Signature                                         Office Held                                          Date

                                                                                                                                         PDK Form 103 (Rev. 6/07)

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