I hereby wish to

I hereby wish to (check one only)

Join as a new member into:

Reinstate into:

Transfer into:

Chapter #

District #

Located in (City):

State:

Prefix (Mr./Dr.)

Last Name

Suffix (DDS, Esq)

First Name

Nickname

Middle Initial

Address

City

State

Province

Country

Homephone

Workphone

FAX

Date of Birth

Are you a citizen of the US or Canada yes no

Were you a member of the Sons of Pericles? yes no

Chapter City State

FOR REINSTATEMENT ONLY

Serial Number

Date Initiated

I hereby apply for reinstatement of my AHEPA membership into Chapter #

I was previously a member of Chapter #

Located in

I hereby certify that I have paid my dues up to (date)

to Chapter

FOR MEMBERSHIP TRANSFER ONLY

Serial Number

Date Initiated

I hereby apply for transfer of my AHEPA membership from Chapter #

located in

To Chapter #

Located in

I hereby certify that I have paid my dues up to (date)

to Chapter

I believe myself worthy of the rights and privileges enjoyed by the members of AHEPA. I know no reason why I should not become a member, and I promise, if accepted, to observe the laws and traditions of AHEPA, and will not take advantage of or abuse my privileges as a member thereof. I believe in the Divinity of Jesus Christ.

Signature

Date