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

INVOICE 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
  - Regalia Orders
  - Conference Invoices
- OMR Balance Payment
  - Annual Chapter Fee
  - Member Dues
Member / Chapter Information
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)

Other
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:
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 ($350)
USD
Additional Annual Conference Chapter 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:

USDThis field is required for the payment to successfully process

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

If you have any questions about your invoice total, please contact the National Office by email at mortarboard@mortarboard.org or call us at 614-488-4094
Confirm humanity
Should be Empty:

INVOICE PAYMENT FORM