Membership Verification Form

Please complete this form at least 3 days prior to attending a chapter meeting. Once your membership is verified, we will contact you. This form is ONLY for members of Delta Sigma Theta and NOT for persons interested in membership.
Please submit your information before visiting out chapter meetings.

Membership Verification Form:

* Indicates required field

Name *

First

Last

Maiden Name *

Street Address *

Address Line 2 *

City *

State *

Zip *

Email *

Birthday (MM/DD) *

Home Phone: *

Cell Phone: *

Full name at the time of initiation: *

Date of Initiation: (approximate month/year) *

Chapter of Initiation: *

Membership Number: *

Membership Status: *

Active Inactive

Select National Membership Status *

Regular Golden Life Diamond

Full name when last active: (Full name at last time you paid Grand Chapter Dues) *

Date (mm/dd/yyyy) *

Submit