RECLAIM MEMBER FORM

Enter your information below. You will be contacted shortly by a local
Reclamation Chair in your area regarding the reclamation process.

(* denotes required)

Member ID (i.e. your 9-digit Control Number)

Chapter of Initiation *
Initiation Date *

Last Chapter of Affiliation

Please provide current address information below:

First Name * Middle Name Last Name *

Home Address * City * State * Zip *

Preferred Contact Number * Home Phone Email *