*Chapter/Colony Name:

— Please Select One — Bloomsburg Chapter — Bloomsburg, PA California Chapter — Berkeley, CA California University of PA Chapter — California, PA Carleton Chapter — Ottawa, Ontario (Canada) Central Oklahoma Chapter — Edmond, OK Colorado Colony — Boulder, CO 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 Long Beach State Colony — Long Beach, CA 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 — West Lafayette, IN Rensselaer Chapter — Troy, NY Saint Cloud State Chapter — Saint Cloud, MN Syracuse Chapter — Syracuse, NY Texas Chapter — Austin, TX Toronto Colony - Oakville, Ontario Washington State Colony — Pullman, WA Wisconsin Chapter — Madison, WI Western Ontario Colony — London, Ontario (Canada)

*Chapter Roll No. (PIN):
If registering a pledge, please enter "PLEDGE" in the box above.

*Membership Type:    Active    Pledge    Honorary

Instructions: This is the initiate's Official Membership Record. It is important that this record be filled out completely and correctly. The Chapter/Colony Secretary or Pledge Educator is responsible for completing this form and retaining a copy of this information in the Chapter/Colony files. In accordance with the Law of Acacia, membership records and fees are to be sent to Acacia Fraternity Headquarters within 72 hours of initiation.

*First Name:

*Middle Name:

*Last Name:

*e-mail Address:

*Address:

*City:

*State/Territory: — Please Select One — 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 CANADA

*Postal Code:

*Home Phone with Area Code:

FATHER/GUARDIAN

Name:

Vocation:

College Attended:

Is father a member of a fraternity?     Yes     No

If yes, name of fraternity:

MOTHER/GUARDIAN

Name:

Vocation:

College Attended:

Is mother a member of a sorority?     Yes     No

If yes, name of sorority:

PERMANENT CONTACT

Please list below the name and address of a relative or friend who will know the initiate's contact information throughout his lifetime:

Name:

Address:

City:

State/Territory: — Please Select One — 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 CANADA

Postal Code:

Home Phone with Area Code:

eMail:

*Social Security Number:

*Date of Birth:

*Year In School:    Freshman    Sophomore    Junior    Senior

*Date of Pledge Induction:

*Date of Initiation:

Date Entered College:

Expected Graduation Date:

Major/Curriculum:

Legacy?    Yes     No

Names of Relatives in Acacia:

To Acacia Fraternity Headquarters:

I hereby certify that the person named above is fully qualified for membership under the Constitution and Bylaws of Acacia Fraternity, and is connected with the institution of learning at which this Chapter or Colony is located.

*Date:

*Official's Name:

*Official's Title: — Please Select One — Venerable Dean Senior Dean Junior Dean Secretary Treasurer Pledge Educator Chapter/Colony Advisor Other

*Official's e-mail Address: