Phi Theta Kappa - Beta Epsilon Theta: Membership Application

FQK Membership Application

All fields are required Printable Version

Student Id (i.e. LUABUR1234):

First Name:

Middle Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Phone (home):

Alternate Phone (work):

Alternate Phone (cell):

Email:

Est. Graduation Date:

Major (i.e. Networking):

Current Term (dues):	:	Enrollment Type:
1-12 ($60.00) 13-16 ($70.00) Later than term 16 ($80.00)		Day Night Online
Payment Option:
Cash(do not send cash in mail) Credit Card (Visa or Mastercard $2.50 service fee) Pay Pal Already paid on international site Check(make payable to PTK) Payment Plan(weekly $5.00) Payment Plan(biweekly $10.00) Financial Aid(upon approval)


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