New SHPE Jr. Chapter Application Form

Chapter Information
Sponsoring Chapter
Chapter Name *
Must include SHPE in the name
School Name *
Region: *
Chapter Address *

Street Address

Street Address 2

City State / Province

Postal / Zip Code Country
Chapter Phone Number
Optional
Chapter Email Address:
Chapter Website:
Major Activities/Events
Estimated Annual Operating Budget
Total Members *
Social Media (optional):
Facebook
Instagram
LinkedIn
Snapchat
Twitter
TikTok
SHPE Chapter Leadership
President *

First Name Middle Name Last Name
*
E-Mail
Member ID Number *
This number is found on your SHPE Connect account
Vice President *

First Name Middle Name Last Name
*
E-Mail
Member ID Number *
This number is found on your SHPE Connect account
Treasurer *

First Name Middle Name Last Name
*
E-Mail
Member ID Number *
This number is found on your SHPE Connect account
Secretary *

First Name Middle Name Last Name
*
E-Mail
Member ID Number *
This number is found on your SHPE Connect account
Month Elections are held:
Student Chapter Information
Chapter Advisor *

First Name Middle Name Last Name
Title
Advisor Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Advisor E-mail Address *
Advisor Phone Number *
Chapter Representative

First Name Middle Name Last Name
Representative Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Representative Phone Number
Representative E-mail Address
Academic System
Please provide, at minimum, six junior members in your chapter. Do not include your chapter leadership.

Founding Member 1
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account

Founding Member 2
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account

Founding Member 3
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account

Founding Member 4
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account

Founding Member 5
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account

Founding Member 6
Name *

First Name Last Name
Member ID Number *
This number is found on your SHPE Connect account
Do you have more founding members to include? *

Yes No

Founding Member 7
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Founding Member 8
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Founding Member 9
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Founding Member 10
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Founding Member 11
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Founding Member 12
Name

First Name Last Name
Member ID Number
This number is found on your SHPE Connect account

Chapter Information

Social Media (optional):

SHPE Chapter Leadership

Student Chapter Information

Authorization Page