Please TYPE and send completed form to the Province Director of Chapters to keep on file. Only initiated members may apply.

Name: | Groch | Jessie | Date Form Mailed: | Due to Jordan Kirkland by Friday, Nov. 22, 2013 | | (Last) | (First) | | | Semester | Chapter: | Epsilon Eta | University: | Auburn | Trimester | | Quarter | Province: | | Have you applied before? | no | Date: | 2/1/2014 | Home Address: | 307 Stanwood Court | Florence, AL 35633 | | (Number and Street) | (City, State and Zip Code) | Your Current Address: | 307 Stanwood Court | Florence, AL 35633 | | (Number and Street) | (City, State and Zip Code) | Telephone Number: | (256) 443-2219 | Email: | jmg0041@auburn.edu | Date of semester(s) or term(s) you wish Associate Membership: | January 2014 | August 2014 | | (From Month/Year) | (To Month/Year) | Class you will be during this time: | Soph | (Soph.-Jr.-Sr.) | | Jessie Groch | | | (Applicant signature) | |

In the space below please state briefly but clearly your reasons for requesting Associate Membership. | |

Please obtain the following signatures approving your application. Encourage any of these to write to the Province Director of Chapters directly if they feel further comment is necessary. If a letter is accompanying this application, CHECK HERE .

Did your Advisory Board approve this request? | | Yes | | No | Advisory Board Chairman Signature: | | Address: | | | | | (Number and Street) | (City, State and Zip Code) | (Email) | | Yes | | No | | Is the applicant in good standing? | | Yes | | No | | Has applicant paid all dues to date? | | Yes | | No | | N/A | If application is for financial reasons, is member working regularly? | | Yes | | No | | N/A | Has every effort been made to assist with her financial situation? | | Yes | | No | | Has per capita fee been paid for the term of Associate Membership? | | (Must be paid/or have been paid for the academic year for which the request is being made before submitting this application) | | Yes | | No | | Is the applicant receiving a Kappa Kappa Gamma scholarship? | | Finance Adviser Signature: | | Address: | | | | | (Number and Street) | (City, State and Zip Code) | (Email) | Chapter President Signature: | | Email: | | Chapter Treasurer Signature: | | Email: | | Physician Signature (if health is involved): | | Address: | | | | | (Number and Street) | (City, State and Zip Code) | (Email) |

For PDC only: | Application | | granted | | denied |