First Name:

Last Name:

Chapter/Colony: — Please Select One — Bloomsburg Chapter — Bloomsburg, PA California Chapter — Berkeley, CA California University of PA Chapter — California, PA Cal State Long Beach Colony — Long Beach, CA Carleton Chapter — Ottawa, Ontario (Canada) Central Oklahoma Chapter — Edmond, OK Cornell Chapter — Ithaca, NY Illinois Chapter — Champaign, IL Illinois Wesleyan Chapter — Bloomington, IL Indiana Chapter — Bloomington, IN Indiana University of PA Chapter — Indiana, PA Iowa State Chapter — Ames, IA Kansas State Chapter — Manhattan, KS Louisiana State Chapter — Baton Rouge, LA Louisiana Tech Colony — Rustin, LA Miami of Ohio Chapter — Oxford, OH Millersville Chapter — Millersville, PA Missouri Chapter — Columbia, MO Morningside Chapter — Sioux City, IA Nebraska Chapter — Lincoln, NE Northwestern OK State Chapter — Alva, OK Ohio Chapter — Athens, OH Ohio State Chapter — Columbus, OH Oregon State Chapter — Corvallis, OR Penn State Chapter — State College, PA Penn State/Altoona Chapter — Altoona, PA Pittsburgh/Johnstown Chapter — Johnstown, PA Purdue Chapter — Lafayette, IN Rensselaer Chapter — Troy, NY Saint Cloud State Chapter — Saint Cloud, MN Shippensburg Chapter — Shippensburg, PA Syracuse Colony — Syracuse, NY Texas Chapter — Austin, TX Wisconsin Chapter — Madison, WI UCLA Colony — Los Angeles, CA Western Ontario Colony — London, Ontario (Canada)

Don't see your Chapter on the above list?  Please type it in here:

Position: — Please Select One — Venerable Dean Senior Dean Junior Dean Chapter/Colony Advisor Active Alumnus Other

If "Other" was selected, please fill in your position below:

Chapter Roll No. (PIN):

Address Line 1:

Address Line 2:

Address Line 3:

City:

State/Territory: AK — Alaska AL — Alabama AR — Arkansas AZ — Arizona CA — California CO — Colorado CT — Connecticut DC — District of Columbia DE — Delaware FL — Florida GA — Georgia GU — Guam HI — Hawaii IA — Iowa ID — Idaho IL — Illinois IN — Indiana KS — Kansas KY — Kentucky LA — Louisiana MA — Massachusetts MD — Maryland ME — Maine MI — Michigan MN — Minnesota MO — Missouri MS — Mississippi MT — Montana NC — North Carolina ND — North Dakota NE — Nebraska NH — New Hampshire NJ — New Jersey NM — New Mexico NV — Nevada NY — New York OH — Ohio OK — Oklahoma OR — Oregon PA — Pennsylvania PR — Puerto Rico RI — Rhode Island SC — South Carolina SD — South Dakota TN — Tennessee TX — Texas UT — Utah VA — Virginia VI — Virgin Islands VT — Vermont WA — Washington WI — Wisconsin WV — West Virginia WY — Wyoming

Postal Code:

Home Phone with Area Code:

Daytime Phone with Area Code:

eMail:  

Will your spouse/significant other be joining you at Conclave?     Yes     No

If yes, Name:

Please select which Registration Package you would like from the following:

Full Package — $110/person (All Sessions, Programs & Dinners)   BEST VALUE!

Scholarship Banquet Only — $60/person (Friday Night)

Closing Banquet/Centennial Celebration Only — $70/person (Saturday Night)

I would like to attend the FREE Alumni Reception (Friday Night)

How many will be in your party?

Payment Method:     Check     VISA/MasterCard

If paying by check...

After you have filled out this form completely, click the "Submit" button below to send your registration information to the office. Then, please make your check out to "Acacia Fraternity" with "Conclave Registration" in the memo field and mail it to:

Acacia Fraternity
8777 Purdue Road
Suite 225
Indianapolis, IN 46268

If paying by credit card...

After you have filled out this form completely, click the "Submit" button below to send your registration information to the office. You will be automatically redirected to a new webpage to compete your secure online payment transaction.

— PLEASE PRINT A COPY OF THIS FORM FOR YOUR RECORDS —