I hereby wish to: (Check one only)
Join as a new member into:Reinstate into:Transfer into:

Chapter #

District #

City

(State/Prov.)

Prefix (Mr./Dr.)

Last Name

First Name

Address

City

State/Prov

Zip

Country

Phone

Email

Date of Birth

Are you a citizen of the United States or Canada?
YesNo

Were you a member of the Sons of Pericles?
NoYes

Chapter #

City & State/Prov

FOR REINSTATEMENT ONLY

Serial #

Date Initiated

I hereby apply for reinstatement of my AHEPA membership into Chapter #

I was previously a member of Chapter #

located in

I hereby certify that I have paid my dues up to

to Chapter #

FOR MEMBERSHIP TRANSFER ONLY

Serial #

Date Initiated

I hereby wish to transfer my AHEPA membership from Chapter #

located in

To Chapter #

located in

I hereby certify that I have paid my dues up to

to Chapter #

I believe myself worthy of the rights and privileges enjoyed by the members of AHEPA. I know no reason why I should not become a member, and I promise, if accepted, to observe the laws and traditions of AHEPA, and will not take advantage of or abuse my privileges as a member thereof. I believe in the divinity of Jesus Christ.

Initials

Date