APPLICATION FOR PSI CHI MEMBERSHIP

Please Complete and return to the Psi Chi mailbox in Room 119.

Name: __________________________________________________________

SSN: ___________________________________________________________

Address: ________________________________________________________

Phone: ____________________ E-mail: _______________________________

Classification: _____ SO-2nd Semester _____ JR _____ SR _____ GRAD

How many semesters of college have you completed? ___________________

Estimated Graduation Date (month/year): _____________________________

Estimated Cumulative GPA: __________

Estimated Psychology GPA: __________

Psychology Courses Taken to date:

        Course (Name & Number)                                                                    Grade Received

1. _____________________________________________________________________________

2. _____________________________________________________________________________

3. _____________________________________________________________________________

4. _____________________________________________________________________________

5. _____________________________________________________________________________

6. _____________________________________________________________________________

7. _____________________________________________________________________________

8. _____________________________________________________________________________

9. _____________________________________________________________________________

10. ____________________________________________________________________________

I hereby authorize the Psi Chi faculty advisor to review my college records for the sole purpose of determining my eligibility for becoming a member of Psi Chi.

____________________________________________________

(signature of applicant)