Membership Verification Form

Membership Verification

This form is ONLY for members of Delta Sigma Theta and NOT for persons interested in membership.

Please submit your information before visiting our chapter meetings.

Member Verification

First Name(Required)

Last Name(Required)

Maiden Name

Street Address(Required)

Address Line 2(Required)

City(Required)

State(Required)

Zip Code(Required)

Birthdate (MM/DD)

Home Phone

At least one phone number is required.

Cell Phone

At least one phone number is required.

Full name at time of initiation(Required)

First Last

Date of Initiation:(Required)

Approximate month/year

Chapter of Initiation:(Required)

Membership #

(If known)

Membership Status:(Required)

Regular

Golden Life

Diamond Life

Delta Dear?

Yes

Last Active Chapter(Required)

Last chapter in which you paid Grand Chapter Dues.

Full name when last active:(Required)

First Last

Full name at last time you paid Grand Chapter Dues.

Date

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