Name _____________________________________________________________________________

Phone Number ________________________ Email Address ___________________________

Activation Date ________________________ Graduation Date __________________________

What offices have you held?

_____ Student teaching What school are you student teaching at? ________________________

_____ Internships What company/organization are you working for? _________________

_____ Co-op program What company/organization are you working for? _________________

_____ Studying abroad What country are you going to? ________________________________

_____ Short-term financial circumstance Please give a detailed explanation of what is going on.

_____ Short-term health circumstance Please give a detailed explanation of what is going on.

_____ Other Please provide complete information on situation so an educated decision can be made.

_______________________________________________ ____________________

Signature Date

Executive Vice President – Please sign stating that this sister is in good standing in your chapter.

_______________________________________________ ____________________

Signature Date

Date Received by National Office _____

Date Received by NEC VP of Membership _____ Approved _____ Not Approved _____

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PHI BETA CHI

MEMBERSHIP SUSPENSION

Name of member suspending:                                                                                                      

Current address:

Permanent address:

School Phone:                                                     Permanent Phone:

Email address:                                                   Graduation date:

Chapter/colony:                                                 Activation date:

Committee Membership/offices held (Please include dates)

Reason for suspending membership (Please include letter if not enough room below):

Verification by financial director:­_______________________ owes $______ to Phi Beta Chi

 Financial director signature and date ____________________________________________

Signature:____________________________________Date:_____________