CHAPTER PAYMENT [Outstanding Balance - Member Dues/OMR Invoice - Chapter Fee/Conference Fee

CHAPTER PAYMENT FORM

Please have your invoice or OMR available as a reference so you can pay your chapter's balance online.
Please use this form for the following payments:
- Outstanding Balance Payment
- Member Dues / Official Membership Report (OMR)
- Annual Chapter Dues/Conference Dues Payment
- Additional Registrations for Annual Conference
Chapter Information
Chapter's institution *
ex. South Dakota State University
Chapter Name
ex. Purple Tassels Chapter
Your name*

First NameLast Name
Phone number*

Area CodePhone Number
Email*
Chapter Role*
(ex: Advisor, President, Treasurer)
Reason for Payment
Reason for Payment (Select all that apply)*

Outstanding/Previous Invoice BalanceMember Dues (OMR)Annual Chapter Fee/Conference FeeAdditional Conference Registration FeeOther
Additional Information Regarding Payment
OMR/Membership Dues (if applicable)

If paying member dues, please either (1) upload below the updated OMR / a list of names, or (2) include names and/emails in the space provided of members.)
If paying your OMR (Official Membership Report), which applies:

Member Dues OnlyAnnual Chapter/Conference Fee Only ($350)Member Dues and Annual Chapter/Conference FeeNot Applicable
Upload the updated OMR or a list of member names for dues included in payment.

Browse Files

Cancelof
List member names for dues included in payment.
PAYMENT AMOUNT

Please enter the amount due (US dollars) for each applicable payment.
Outstanding Invoice Balance Amount
USD
Membership Dues (Members paid to chapter X100)
USD
Annual Chapter Fee / Conference Fee
USD
Additional Annual Conference Registration Fee ($350 per additional registrant + any single room upgrades if applicable)
USD
PAYMENT INFORMATION
We would like to apply local dues to cover amount (or a portion) of balance due:

YesNoUnsure

TOTAL Invoice or Chapter Balance Amount

USDInvoice dollar amount (refer to OMR part 4 if needed)

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

If you have questions about how your OMR spreadsheet calculated the invoice total, please contact mortarboard@mortarboard.org and attach a copy of your completed OMR.

Or, please call the National Office at 614-488-4094.
Confirm humanity*
Should be Empty:

CHAPTER PAYMENT FORM

Chapter Information

Reason for Payment

OMR/Membership Dues (if applicable)

PAYMENT AMOUNT

PAYMENT INFORMATION