Nu Gamma Omega Chapter Visiting Member Form
Please complete the form in its entirety. You may present this form to the Chapter Basileus, Anti Basileus, Hodegos, Philacter or Membership Chairman. Thank you.
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guest Of-List Member Name (if applicable)
Member Status
*
Active
Inactive
General
Most Recent Chapter
*
Chapter City, State, Region
*
Chapter of Initiation
*
Financial Card Number
Ivy Leaf Presented
Yes
No
Other
Photo ID Presented
Yes
No
Status
*
Reactivating
Transferring
Visiting
Other
Have You Visited With Us Before?
*
Yes
No
If yes, list date of last visit.
-
Month
-
Day
Year
Date
Other Information
Submit
Should be Empty: