Membership Application Form

Phi Beta Kappa Alumni in Southern California

PBK Key - a link to the opening page

Please print out and complete this page. Send it, along with your check or money order for $35 payable to:

PBK Alumni in Southern California
12814 Riverside Dr.
North Hollywood, CA 91607

MEMBERSHIP APPLICATION

Title:	Mr./Ms./ Mrs./ Miss/ Dr.
Full Name:	____________________________________
Address:	____________________________________
	____________________________________
City:	____________________________________
State:	_____________ Zip:_________________

Employer:	____________________________________
Job Title:	____________________________________
Work Phone:	______________________
Home Phone:	______________________
E-mail:	______________________

School:	____________________________________
Year Initiated:	__________
Major/Degree:	____________________________________

Name at Initiation: (e.g. maiden name)	____________________________________

Circle the standing committees that you would be interested in serving on:
	Program Committee Development Newsletter Audit Membership	New Phi Betes Graduate Scholarships International Scholarships High School Awards Web Site