Phi Alpha Theta s1

PHI ALPHA THETA MEMBERSHIP APPLICATION

First Name: ______Middle Initial:____ Last Name: ______

Permanent address [for mailing The Historian]:

Street: ______

City, State, Zip: ______

Telephone: (____) ______

Local/Campus address:

Street: ______

City, State, Zip: ______

Telephone: (____) ______E-mail address: ______

Dates at LSU: ______

Major(s) at LSU: ______Minor(s):______

Expected degree(s): ______Expected date of graduation: ______

Other Colleges/Universities attended: ______

______

Dates: ______

Major: ______Minor: ______Degree: ______

Date of graduation: ______

Clubs/activities: ______

______

Historical interests: ______

______

Please enclose a check for $50 made out to Phi Alpha Theta, Zeta Eta Chapter. Turn in completed application and check to Prof. Carolyn Lewis, Dept. of History, 231B Himes Hall, LSU, Baton Rouge, LA 70803. ______

Do you have an interest in . . .? [check any that apply]

A graduate degree in History ____ Law school ____ Teaching in High School ____

Other graduate program ____ Describe: ______

Please enclose a check for $50 made out to Phi Alpha Theta, Zeta Eta Chapter. Turn in completed application and check to Prof. Carolyn Lewis, Dept. of History, 231B Himes Hall, LSU, Baton Rouge, LA 70803.