Initiation Form
ETA SIGMA GAMMA
Alpha Omega Chapter
University of Nebraska at Omaha

General Information
Note: Print this form and fill in all requested information. Send completed form to address shown at the end of this page.

Name_________________________________________       SS#__________________________
           Last                                                First                                middle

Present address _______________________________
                         street                city
                         _______________________________                        (____)_______________
                         state                    zip                                                                                    phone

Permanent address_______________________________
                         street                city
                         _______________________________                        (____)_______________
                         state                    zip                                                                                    phone

Major____________________________________ Email ________________________

Year Initiated____________________________

Circle the appropriate

Male        Female

Undergraduate -- Freshmen        Sophomore        Junior        Senior

Graduate -- 1st year        2nd year        2nd year+

Fill in the requested information:

Total hours completed______________ Total health related hours completed ______________

Expected graduation date_____________  Major GPA_________ Cumulative GPA_________


First year initiation = $55.00  ($5.00 National Initiation fee + $25.00 National Annual fee (includes student membership to the Public Health Association of Nebraska)
                                              + $5.00 Local Initiation fee + $15.00 Local dues)

Annual renewal = $40.00  ($25.00 National renewal fee + $10.00 Local renewal fee)

Life Membership = $350.00 ($200.00 National fee + 150.00 Local fee)
 

I am paying for:    Renewal_______  First year initiation_______   Life membership_______

Initiation Form
ETA SIGMA GAMMA
Alpha Omega Chapter
University of Nebraska at Omaha





Name -- as you want it to appear on certificate

_______________________________________________________________
 

Address -- where journal can be sent

_______________________________________

_______________________________________

____ First Year Initiate                ___ Renewal Member                ___ Life Member


 

Make checks payable to: ETA SIGMA GAMMA -- Alpha Omega Chapter
 

Return completed forms to either Dr. Corbin or Dr. Sharma
 

Mail to:    University of Nebraska at Omaha                    Fax number: (402) 554-3693
                School of HPER-- room 207
                6001 Dodge Street
                Omaha, NE  68182
 
 

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