FULL NAME: __________________________________________________ 

ADDRESS: ___________________________________________________

CITY: ____________________________ STATE: ___ ZIP: _____________ 

HOME PHONE: ( ) _____________ BUSINESS PHONE: ( ) _______________

E-MAIL: _________________________ FAX: ( ) _____________________ 

CHAPTER: ______________________________ REGION: _____________ 
*(THIS IS A NEW ADDRESS _____) 

AMOUNT CONTRIBUTED: 
(1) ____ $500 (2)____ $300 (collegiate) (3)$ _____ OTHER (MUST BE MORE THAN $500)

INFORMATION TO BE INCLUDED ON EACH PLATE (PLEASE COMPLETE ONLY ONE SECTION FOR EACH FORM): 

1. INDIVIDUAL BROTHER: 

NAME   FIRST: ___________________________ MI: __ LAST: __________________________

DATE OF INITIATION: _______________

2. CHAPTER: (ENTIRE CHAPTER)                     3. REGION 

NAME: _____________________________      NAME: ________________________________

DATE FOUNDED: _______________                 DATE FOUNDED: ______________

4.CHAPTER (INTAKE BROTHERS): *Any group of Brothers who were initiated together

CHAPTER NAME: ___________________ INITIATION DATE: _______________

METHOD OF PAYMENT: (FULL PAYMENT MUST ACCOMPANY ALL FORMS) 

__ PERSONAL CHECK  __ MONEY ORDER   
__ CERTIFIED OR CASHIER’S CHECK PAYABLE TO PHI BETA SIGMA FRATERNITY, INC. 

CREDIT CARD PAYMENT: 

___ VISA ___ MASTERCARD ___ AMERICAN EXPRESS ___ DISCOVER 

CARD #: ___________________________        CARD EXPIRATION DATE: __________________

SIGNATURE ______________________________ (required for credit card use only) 

PLEASE NOTE THE FOLLOWING: 
• THE MINIMUM PAYMENT REQUIRED IS $500.00; HOWEVER, TO HELP OFFSET COSTS FOR THE WALL, 
   ANY AMOUNT ABOVE $500.00 IS WELCOMED.  

• NO PARTIAL PAYMENTS WILL BE ACCEPTED, PLEASE SEND THE FULL AMOUNT.

• NO DISTINCTIONS WILL BE MADE BASED ON AMOUNT CONTRIBUTED. 

• ONLY TWO (2) LINES PER PLATE CAN BE ACCOMMODATED ( 1. NAME, 2. DATE) 

• FOR DATE OF INITIATION, THE FOUR (4) SEASONS MAY BE USED: I.E. FALL 1950. 

• NO SLANG OR NICKNAMES WILL BE ACCEPTED.