*1.Contact Information(Required.)

Name *

Phone *

Address 1

Address 2

City *

State *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

Zip *

Email Address *

*2.Employer(Required.)

*3.Job Title

• If faculty, please indicate rank and field.
• If retired, please include your most recent full-time position.
• If a student, please indicate degree sought and anticipated graduation date.

(Required.)

*4.Year of Initiation (To be eligible to serve on a committee, members must have been initiated in 2015 or earlier.)(Required.)

*5.Phi Kappa Phi Chapter(Required.)

*6.Top 3 Committee Choices [See committee descriptions here.]:(Required.)

Budget and Program Review

Bylaws

Forum Advisory Council

Investment

Nominating

Dissertation Fellowship Selection

Graduate Research Grant Selection

Fellowship Selection

Literacy Grant Selection

Love of Learning Award Selection

Scholar, Artist and Ray Sylvester Distinguished Service Awards Selection

Study Abroad Grant Selection

*7.Please explain why you are interested in serving on the committees selected above. Be sure to include specific and relevant professional experience.(Required.)