Check If You Would Like All Correspondence to Go to the Campus Advisor

COUNCIL INFORMATION:

Check if you would like all correspondence to go to the campus advisor

Name: Graduate Undergraduate (Example: NPHC of Howard University or NPHC of Dallas) Address: City: State Zip Code: : Tele: Fax: Email: Council Website:

OFFICER INFORMATION:

President: Tele: h/c w Email: Treasurer Tele: h/c w : Email: DEMOGRAPHICS: List the names of each financially active chapters in your council (Attached additional page, if necessary)

Chapter should be referenced by Member Organization-Chapter Name (e.g. -Delta Lambda)

COUNCIL ADVISORS: if applicable

Campus Tele: h/c w Advisor: Email:

Alumni Tele: h/c w Council Advisor: Email:

Qty Item Cost Notes

Undergraduate Council Dues $150.00

Alumni/Graduate Council Dues Alumni/Graduate Council dues are determined by the number of chapters affiliated 1-9 Chapters = $250 with the Council. 10-19 Chapters = $300 20-29 Chapters = $350 30+ Chapters = $450 Late Fee $25.00 MUST add to dues if postmarked after February 15 Reactivation Fee $50.00 Pertains to councils not financial in previous fiscal year; in addition, dues for previous and current FY must be remitted Charter Fee $100.00 Please include appropriate council dues

Replacement Charter $20.00 Note: Charters prior to 1994 may not be available Lapel Pin $15.00 NPHC Badge 1- $10 2-$15

Total $ Payment Type (check): MO Check Online Remitter: Date: