MEMBERSHIP REGISTRATION FORM

LAST NAME FIRST NAME MIDDLE NAME SUFFIX PREFIX NICKNAME

CHAPTER SCHOOL & LOCATION POSITION & YEAR

BATCH NAME BAPTISMAL NAME BATCH YEAR RITUAL DATE (MM/DD/YYYY)

DATE OF LAST REGISTRATION

RESIDENT BROTHER RESIDENT SISTER ALUMNUS ALUMNA LIFE ASSOCIATE
(MM/DD/YYYY)
AGE BIRTH DATE (MM/DD/YYYY) BIRTHPLACE BLOOD TYPE

HOMETOWN ADDRESS ZIP CODE TELEPHONE FAX

RAD I:
MAILING ADDRESS ZIP CODE TELEPHONE FAX

E-MAIL ADDRESS WEB SITE CELL PHONE CHAPTER:

COURSES TAKEN SCHOOL YEAR

ID NUMBER:

RAD II:

PROFESSION/TRADE/OCCUPATION & COMPANY POSITION

BUSINESS ADDRESS ZIP CODE TELEPHONE FAX

DATE FILED:
ALUMNI ASSOCIATION POSITION HELD YEAR

ORGANIZATION (OTHER THAN APO) POSITION HELD YEAR By: ________________

RESULTS OF
CHAPTER POSITION HELD; GC/GLC & PC/PLC ONLY (CHAPTER : POSITION : SCHOOL YEAR) VERIFICATION:

____________________
CHAPTER &/OR ALUMNI ASSOCIATION ORGANIZED (CHAPTER/AA NO. : YEAR) DB Record No.

INSURANCE BENIFICIARY RELATIONSHIP ____________________

Verifier
COMPLETE ADDRESS TELEPHONE
____________________
ID No.
MEMBERSHIP RE-AFFIRMATION PLEDGE
ON MY OATH, I hereby affirm that I shall abide by our National Code of By-Laws; comply with all lawful orders of our duly constituted leadership; maintain my
good standing by fulfilling the duties of membership; endeavor to realize the ideals of the organization by excelling in my chosen field, by extending a hand of
DATE FEE PAID:
friendship to all regardless of race, religion, social class, or political ideology, and by unselfishly giving my time and energy in pursuing a program of service to our
fraternity and sorority, to the students and university, to the youth and community, and to the nation as a fully participating citizen. I shall, in all my dealings,
uphold the dignity of Alpha Phi Omega by good example through thoughts, words, and deeds. Amount:
All these I do promise without mental reservation or purpose of evasion. SO, HELP ME, GOD.

Signature: Date: O.R. No.:

FOR NEW APPLICATIONS & SPECIAL CASES ONLY ID NO. : VALIDITY REMARKS & SIGNATURE
ENDORSEMENTS (GC/GLC OR PC/PLC PLEDGE PERIOD) Validity:
:
OTHER (NAME : POSITION : SCHOOL YEAR)
: Control No.:
SECTION CHAIR
:
REGIONAL DIRECTOR
____________________
: Received by
NATIONAL EXECUTIVE DIRECTOR
REINALD D. RELOVA 08448 : 2015-2017 :
____________________
FOR VERIFICATION (ALL NEW APPLICATIONS AND THOSE FALLING UNDER SPECIAL CASES) ID No.
GC/GLC AT DATE OF JOINING MY IDENTIFYING MARKS OR UNUSUAL FEATURES

PC/PLC AT DATE OF JOINING

DATE ENCODED:
BATCHMATES

____________________
TOTAL BATCHMATES Encoder
OTHER REFERENCES (FROM SAME CHAPTER) ADDRESS/PHONE
____________________
ID No.