Sample Membershipapplication Form by gcv65107

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									                           Alpha Kappa Alpha Sorority, Incorporated Undergraduate Membership Interest Application
                     (This form must be signed in the presence of a licensed notary. See page III-14 of the application)
      I understand that falsification of any information on this application or attachments will eliminate me from being considered for
                                         membership into Alpha Kappa Alpha Sorority, Incorporated
 CHAPTER INFORMATION                                                                      ACADEMIC BACKGROUND (cont’d)
 ___________________________________________________ _________                           2.    List any activities that have allowed you to serve as a role model for girls and/or
 Chapter of Interest                                  Date                                     women on your campus or in your community:
                                                                                               ________________________________________________________________
 __________________________ _________________________ _________
 College/University         City/State                 Country                                 ________________________________________________________________
 PERSONAL INFORMATION
                                                                                               ________________________________________________________________
 ___________________________ ______________ __________________                           3.    How have you helped to alleviate problems concerning our young girls and
 First Name              Middle Initial            Last Name                                   women on your campus or in today’s society?
                                                                                               ________________________________________________________________
 _______________________ _______________________ _____________
 Home Phone                Work Phone              Cell Phone                                  ________________________________________________________________
 _____________________________ ______________________ ________                                 ________________________________________________________________
 Permanent Address               City/State              Zip
                                                                                              ORGANIZATIONAL KNOWLEDGE
 _____________________________ ______________________ ________
                                                                                         1.    Do you have prior knowledge of Alpha Kappa Alpha Sorority, Incorporated?
 School Address                  City/State              Zip
                                                                                                                        Yes ___ or No ___
 _____________________________________________________________                           2.    In your own words, describe the purpose of Alpha Kappa Alpha Sorority.
 Email Address
                                                                                               ________________________________________________________________
 ______________________________________ ______________________
 List any college organization affiliation Position held, if any/When                          ________________________________________________________________

 ______________________________________ ______________________                                 ________________________________________________________________
 List any college organization affiliation Position held, if any/When                    3.    What talents do you possess that will ensure that Alpha Kappa Alpha Sorority
 ACADEMIC BACKGROUND                                                                           will maintain its status as the premier Greek-lettered service organization for
                                                                                               college-trained women?
 1.    List any academic honors received in the last two (2) years. Please include
                                                                                               ________________________________________________________________
       when and where.
 _____________________________________________________________________
                                                                                               ________________________________________________________________
 _____________________________________________________________________
                                                                                               ________________________________________________________________
 _____________________________________________________________________

                                                                                     III-11
Undergraduate MIP Manual (November 2010)
 ORGANIZATIONAL KNOWLEDGE (cont’d)                                                   AFFIRMATION STATEMENT (cont’d)

 4.  Please list one program you would implement as an undergraduate member
     of Alpha Kappa Alpha Sorority. Describe the target audience and purpose.       3.   Have you previously applied for membership into a sorority that belongs to the
 ________________________________________________________________                        National Pan-Hellenic Council or National Panhellenic Conference?
                                                                                                                      Yes ____ or No ____
 ________________________________________________________________                        If you answered Yes to No. 3, please name the sorority/sororities and explain
                                                                                         why you did not pursue membership with that sorority/sororities.
 ________________________________________________________________
                                                                                         ______________________________________________ ________________
 PERSONAL ASSESSMENT                                                                             Name of Sorority/Sororities        Date of Application(s)
 When placed in a tense situation…                                                       ______________________________________________ ________________

 1. How do you exercise good manners?_______________________________                     ______________________________________________ ________________

 ________________________________________________________________                   4.   Have you read Alpha Kappa Alpha Sorority’s Anti-Hazing Policy?
                                                                                                                     Yes ____ or No ____
 2. How do you handle conflict?
                                                                                    5.   Do you understand Alpha Kappa Alpha Sorority’s Anti-Hazing Policy?
 ________________________________________________________________                                                     Yes ____ or No ____
                                                                                    6.   Have you ever participated in or been accused of hazing as it relates to Alpha
 ________________________________________________________________                        Kappa Sorority, Incorporated? Yes ____ or No ____
 3. How do you strive to create a supportive environment?                           7.    Have you previously applied for membership into Alpha Kappa Alpha Sorority,
 ________________________________________________________________                        Incorporated?                   Yes ____ or No ____
 ________________________________________________________________                   8.   If you answered Yes to No. 7, please list the following:
 AFFIRMATION STATEMENT
                                                                                         ______________________________________________________________
                                                                                         Name of chapter           Name/Location of Institution    Year
 1.   Have you received and read the General Information for the Collegian
      Brochure?            Yes ____ or No ____                                           ______________________________________________________________
                                                                                         Name of chapter           Name/Location of Institution    Year
 2.   Have you been a member of a sorority which belongs to the National Pan-
      Hellenic Council or National Panhellenic Conference?                          9.   Have you ever participated in or been accused of hazing as it relates to any
                           Yes____ or No ____                                            organizations?                     Yes ____ or No ____
 If you answered Yes to No. 2, please name the sorority/sororities and your              _______________________________________________________________
 initiation date(s).
 _____________________________________________________________                           _______________________________________________________________
       Name of Sorority/Sororities          Date(s) of Initiation(s)


                                                                                III-12
Undergraduate MIP Manual (November 2010)
 AFFIRMATION STATEMENT (cont’d)                                                         BACKGROUND CHECK

 10. Have you ever been convicted of a felony?                                          Please read carefully before signing the following:
                 Yes ____ or No ____
                                                                                        As part of the membership application process, Alpha Kappa Alpha Sorority,
 General Disclaimer to All Applicants: Do not answer “Yes” and disclose any             Incorporated will conduct a background check on you. Such a process requires your
 instances of arrests; any misdemeanor convictions; or any convictions that have        permission for Alpha Kappa Alpha Sorority, Incorporated to obtain your consumer
 been expunged, annulled, sealed, statutorily eradicated, pardoned, or dismissed        report from a consumer reporting agency. You will be responsible for the cost
 upon condition of probation.                                                           associated with obtaining your consumer report. Your consumer report, may
                                                                                        include, but not be limited to, the following information: a credit report, consistent
 Disclaimer to California Applicants: Do not answer “Yes” if the felony                 with applicable federal, state and local laws, that includes obtaining information on
 conviction was related to marijuana and such conviction is more than two (2)           convictions and/or pending prosecutions; Department of Motor Vehicles
 years old.                                                                             information; civil suits and judgments within the past seven (7) years; accounts in
                                                                                        collections within the past seven (7) years; and bankruptcies within the past ten (10)
 Disclaimer to Connecticut Applicants: Do not answer “Yes” if the record of             years.
 felony conviction was erased under Connecticut General Statutes Sections 46b-
 146 (records related to determinations of “delinquency” or that, as a child, you       I, ________________________________, hereby authorize Alpha Kappa Alpha
 were a member of a family with service needs), 54-76o (records related to a                 Name of Candidate (Please Print)
 ruling that the applicant was a youthful offender), or 54-142a (records related to
 a finding that the applicant was not guilty for a criminal charge or a conviction      Sorority, Incorporated to conduct a background check and to investigate my
 for which the applicant has received an absolute pardon).                              qualifications as they relate to my becoming a member in the organization for which
                                                                                        I am applying.
 Disclaimer to Massachusetts Applicants: Answer “No or No Record” if you
 have a sealed record with the commissioner of probation with respect to any            I understand that Alpha Kappa Alpha Sorority, Incorporated may utilize an outside
 inquiry relative to prior arrests, criminal court appearances, or convictions.         firm or firms to assist it in checking such information, and I specifically authorize
                                                                                        such an investigation by information services and outside entities of Alpha Kappa
 Disclaimer to Washington State Applicants: Do not answer “Yes” if the                  Alpha’s choice.
 conviction is more than seven (7) years old.
                                                                                        I agree to release and hold harmless Alpha Kappa Alpha Sorority, Incorporated
 If you answered Yes to No. 10, please describe the circumstances.                      from any and all liability with respect to receipt of such information and
 ________________________________________________________________                       acknowledge that Alpha Kappa Alpha Sorority, Inc is relying on third party
                                                                                        information and, therefore, release Alpha Kappa Alpha Sorority, Incorporated, its
 ________________________________________________________________                       agents, officers, and employees from any and all liability arising out of errors or
                                                                                        omissions.
 ________________________________________________________________
                                                                                        I also understand that I may withhold my permission and that in such a case, no
 1.  List the URL of any websites that depicts you in a personal or professional        investigation will be done, and my application for membership may not be
     manner.                                                                            processed further.
 ________________________________________________________________
                                                                                        ___________________________________________________ _____________
 ________________________________________________________________                       Signature of Candidate                                Date



                                                                                   III-13
Undergraduate MIP Manual (November 2010)
 ANTI-HAZING POLICY
                                                                                       AGREEMENT TO ARBITRATION
 Please read carefully before signing the following:
                                                                                       I, __________________________________ affirm that I understand and agree
 I, __________________________________ affirm that the information                             Name of Candidate (Please Print)
        Name of Candidate (Please Print)                                               that any grievances and all disputes brought by prospective members resulting from
  provided in this application and all submitted documentation is true and correct.    claims for personal injury, claims for damages to property, or disputes of any nature
 I acknowledge that I have read, understand and will abide by the policy of Alpha      that cannot be resolved within the Sorority, including those arising from the
 Kappa Alpha Sorority, Incorporated, which forbids hazing. The candidate and           membership intake process, will be referred to arbitration. Any grievances and
 parent(s) or guardian(s) for candidates under the age of twenty-one (21) further      disputes regarding membership intake should be referred to the Regional Director
 agree to indemnify and/or hold harmless for any and all acts of hazing in which       for investigation and resolution. The prospective member specifically agrees to
 the candidate participates and which result in harm to the candidate or anyone        follow all of the rules, regulations, and guidelines relating to the intake process. The
 else from this day forward in perpetuity.                                             prospective member further agrees to report in writing any infractions and
                                                                                       violations of the rules, regulations, and guidelines relating to the intake process. The
 Anti-Hazing Policy                                                                    prospective member acknowledges that Alpha Kappa Alpha Sorority, Incorporated
 Alpha Kappa Alpha Sorority, Incorporated has a strict policy against hazing.          is an international organization with entities located throughout the United States
 Hazing may include, but is not limited to: attending unauthorized rush meetings       of America and abroad. The prospective member recognizes by making this
 or sessions; removing garments; eating or drinking anything given to you as a         application for membership she agrees to the foregoing matters. The prospective
 requirement for membership in Alpha Kappa Alpha Sorority, Incorporate; or             member understands that this agreement has an effect on interstate commerce and is
 being subjected to any form of verbal, physical or mental harassment, or
                                                                                       subject to the Federal Arbitration Act. The prospective candidate, her heirs and
 intimidation. Alpha Kappa Alpha Sorority, Incorporated’s requirement is that
 those interested in membership in Alpha Kappa Alpha Sorority, Incorporated,           assigns, and Alpha Kappa Alpha Sorority, Incorporated, its officers, employees,
 will support our policy against hazing, harassment and/or humiliation of any          agents, affiliates, chapters and members, agree that any and all disputes, conflicts,
 kind.                                                                                 claims, and/or causes of action of any kind whatsoever, including but not limited to:
                                                                                       contract claims, personal injury claims, bodily injury claims, injury to
                                                                                       character claims, and property damage claims arising out of or relating in any
 ___________________________________________________ ____________                      manner whatsoever to membership of Alpha Kappa Alpha Sorority, Incorporated or
 Signature of Candidate                               Date                             to the membership intake process shall be subject to and resolved by compulsory
                                                                                       and binding arbitration under the Federal Arbitration Act, 9 U.S.C. Section 1,
 Candidate’s Date of Birth _____________________                                       et seq., and the commercial rules of the American Arbitration Association.

 ___________________________________________                                           NOTE: THIS SECTION OF THE DOCUMENT MUST BE SIGNED IN THE
 Name of Parent or Guardian (Please Print)                                             PRESENCE OF A LICENSED NOTARY

 ____________________________________________________ __________                       __________________________________________________ _______________
 Signature of Parent or Guardian                       Date                            Signature of Candidate                                Date


                                                                                       __________________________________________________ _______________
                                                                                       Notary Seal and Signature                             Date


                                                                                  III-14
Undergraduate MIP Manual (November 2010)
EVIDENCE OF COMMUNITY/CAMPUS INVOLVEMENT (ECCI) FORM

INSTRUCTIONS:                                                                                1.    How did the program positively impact the population served?
Please record information below regarding your involvement in community/campus
activities or programs that have occurred within the last two (2) years. All                      _______________________________________________________________
applicants must submit at least one (1) but cannot exceed three (3) ECCI forms to
be considered for membership in Alpha Kappa Alpha Sorority, Incorporated.                         _______________________________________________________________

Additional documentation should not be submitted and subsequently will not be                2.    Did you meet the goal of the activity/program? Please explain.
reviewed. This form should be completed in its entirety and any information
documented without signatures will not be accepted.                                               _______________________________________________________________

___________________________________ ________________ ___________                                  _______________________________________________________________
Title of Activity or Program       Start Date           End Date
                                                                                                  _______________________________________________________________
__________________________________________________ _____________
Location of Activity/Program                   # of hours completed                          3.    How did your involvement in the program affect you?

Goal of Activity/Program:                                                                         _______________________________________________________________
________________________________________________________________
                                                                                                  _______________________________________________________________
________________________________________________________________
                                                                                                  _______________________________________________________________
________________________________________________________________
                                                                                         By signing this form, I verify that all of the information I have provided is true
Population Served (check all that apply):                                                and correct. I understand that at any time, Alpha Kappa Alpha Sorority,
                                                                                         Incorporated can rescind any rights or privileges to an applicant based on the
Youth ___   Adults ___   Seniors ___ College Students ___                                submission of false information or documents.

Other (Please Specify)___________________                                                ______________________________________________ ___________________
                                                                                         Signature of Candidate                         Date
Please describe your specific involvement:
                                                                                         ______________________________________________ ___________________
________________________________________________________________                         Name of Supervisor (Please Print)               Title

________________________________________________________________                         _________________________/_____________________/___________________
                                                                                         Email Address                  Work Phone         State and Zip
________________________________________________________________
                                                                                         ______________________________________________ ___________________
________________________________________________________________                         Signature of Supervisor                         Date

________________________________________________________________

                                                                                    III-15
 Undergraduate MIP Manual (November 2010)

								
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