ANNUAL FEES FORM

IMPORTANT: RETURN TO NATIONAL OFFICE WITH CHECK WRITTEN TO CHI EPSILON

CHI EPSILON

University of Texas at Arlington

Box 19316, Arlington, TX 76019-0316


MEMBER NO. ____________________ GENERAL OPERATION FUND

__$15 __$25 __$50 __$100 __ Other $______

 (you select)
FULL NAME: _____________________ TRANSIT SUBSCRIPTION

(3 Yrs/$16.00, 5 Yrs/25.00, or LIFE/$100.00)

(you select)
ADDRESS: _______________________

_________________________________

_________________________________

NATIONAL SCHOLARSHIP CONTRIBUTION (Suggest $5 to $100)
IF NAME OR ADDRESS SHOULD BE CHANGED,
PLEASE NOTIFY THE NATIONAL OFFICE AT:
E-MAIL xehq@uta.edu
or CALL (817)282-2752.
CURRENT SUBSCRIPTION
TRANSIT IN CURRENT SELECTION
(Call or E-mail National Office to find out yours)
  
THANK YOU FOR YOUR CONTINUED SUPPORT.

TOTAL

$


 

Please direct all comments and queries about this page to Dr. Thomas M. Petry, National Secretary-Treasurer.
© 2002 Chi Epsilon. All rights reserved. Last modified