CHI SIGMA
IOTACHI SIGMA
IOTANew Member Application
Name, as you want it to appear on certificate:_____________________________________
Mailing address: ____________________________________________________________
Street:________________________________________ City:________________________
State:____________________________________________ Zip:______________________
Permanent mailing address if different from above:
Mailing address: ____________________________________________________________
Street:________________________________________ City:________________________
State:____________________________________________ Zip:______________________
Telephone-Home:(____) ___________________ Work:(___) ________________________
University you attend:________________________________________________________
Counselor education degree work completed (credit hours): __________________________
__________________________________________________________________________
GPA:_________
MAJOR:_____________________________________
B. APPLICATION FOR PROFESSIONAL MEMBERSHIP
(Please type or print clearly):
Name, as you want it to appear on certificate:_____________________________________
Mailing address: ____________________________________________________________
Street:________________________________________ City:________________________
State:____________________________________________ Zip:______________________
Permanent mailing address if different from above:
Mailing address: ____________________________________________________________
Street:________________________________________ City:_________________________
State:____________________________________________ Zip:______________________
Telephone-Home:(____) ___________________ Work:(___) _________________________
Highest graduate counselor education degree earned:_________________________________
___________________________________________________________________________
___________________________________________________________________________
GPA:____________
CACREP Program:___________________________________________________________
Core Program:_______________________________________________________________
Professional counselor credential:________________________________________________
State (Please specify type and e.g. LPC #000):______________________________________
National (Please specify type e.g. NCC, CRC, #000):_________________________________
MAJOR: _____________________________
C. ELIGIBILITY VERIFICATION:
University:___________________________________________________________________
Chapter Name:_______________________________________________________________
Faculty Assistant to the Executive Director:_________________________________________
*Signature of Assistant to the Executive Director:____________________________________
*Signature denotes verification of complete information and eligibility according to CSI
By-laws. In the absence of a signature, applicants may send their transcripts and
copies of credential with application.
D. DUES:
First year membership:.......................................$030.00
Life Membership:...............................................$250.00
Annual Renewal:................................................$020.00
Additional Contribution (optional):...................$______
Total Enclosed:..................................................$______
Membership dues and contributions are tax deductible in the U.S.
MEMBERSHIP FEE CHARGE ORDER FORM:
Please charge my membership fees to my credit card
(check the appropriate card type):
Credit card type:
Visa _____________ Mastercard _____________________________
Cardholder Name (print): ____________________________________
Account Number:___________________________________________
Signature: _________________________________________________
Return completed application and check or money order
or completed Membership Fee Form to Wendy Enochs or any
of the Rho Alpha Beta chapter officers