Phi Sigma Iota Membership Card
(Please Type or Print)          ___ Key

1______________________________________________________________________
Last Name      First Name                  Middle

2____________________________________________________________________
Permanent Home Address
____________________________________________________________________
City   State   Zip code                          Phone

3.   _____________________________________________________________________
 Date of Initiation       Chapter Number          Initiate’s No. on Chapter list

4.   _____________________________________________________________________
 Name of Institution

5.______________________________________________________________________
 Address of Institution                                  City       State  Zip code

6. ______________________________________________________________________
 Member Classification: Undergrad./Gr. Student, Faculty, Honorary, Life Member

7. ______________________________________________________________________
Major Field of Study

8. ______________________________________________________________________
 EMAIL address

Signature ___________________________   Signature ___________________________
                               New Member                                                    Chapter Faculty Advisor