Upsilon Chi * Student Membersh Chi Sigma Iota

Chi Sig ma Iota - Upsilon Chi * Student Membership1 Application

Chi Sigma Iota – Upsilon Chi Chapter A. APPLICATION (Please type or print clearly) Date: ______UCF Student Membership Application

Name, as you wDate:ant it____ to ______appear on certi ficate:

______A. APPLICATION ______

Name, as you would like it to appear on Membership Certificate: Mailing address: ______Name: ______Mailing Address: ______Name: ______Street: ______Street: ______

City: ______C i ty: ______State: ______Zip: ______State: ______Permanent mailing______address if different from above: ______Street: ______Zip: ______City: ______

Permanent mailState:ing a______ddress if dif feren t fromZip: ab ______ove: Telephone: (_____) ______- ______Street: ______Email address: ______Universities attended: ______C i ty: ______Counselor Education degree work completed (List 3 Specialization courses): State: ______Zip: ______CURRENT GPA: ______(min. 3.5 on 4.0 system) ______

Expected Graduation Date: ______Telephone-Home: (______) ______Program/Track: ______Telephone-Wor k: (______) ______

E-mail address: ______Revised 9-2018 Universi ti es you attended: ______

Counselor Education degree work completed (credi t hours): ______

GPA: ______(min. 3.5 on 4.0 system)

Expected date of graduation: ______

Program/Track: ______

B. FACULTY ENDORSEMENT I ______hereby support the application of ______to become a member of Chi Sigma Iota – Upsilon Chi. Signature of faculty member endorsing candidate: ______

C. ELIGIBILITY VERIFICATION: University: University of Central Florida Chapter Name: Upsilon Chi UCF CSI Chapter Faculty Advisor: Dr. S. Kent Butler *Signature of Upsilon Chi Chapter Faculty Advisor: ______*Signature denotes verification of complete information and eligibility according to CSI By-laws

D. DUES First year membership: **$50.00 (credit card payment only) (**only after local chapter acceptance and completed National online membership application)

Annual Renewal: $40.00 (credit card payment only) Local Annual Dues: $15.00 (attached check/cash to this application) (CHECK PAYABLE TO: Chi Sigma Iota – Upsilon Chi Chapter) ***Tax Deductible Contribution (optional): ______***Membership dues and contributions are tax deductible in the U.S.

APPLICATION CHECKLIST: Completed 9 credit hours (3 Courses) from “Specialization” section of your program Application includes a faculty member endorsement $15.00 Check payable to “Chi Sigma Iota – Upsilon Chi” is attached to application Current Degree Audit is attached to application (GPA of 3.5 or above required)

Place your completed membership application with attached audit and check inside the RED folder in the CSI mailbox located in Suite ED 322 Once your CSI local chapter application is accepted and reviewed YOU will be contacted with instructions on applying to the National CSI. You will visit http://www.csi-net.org/ to complete the registration form and pay National dues (**$50.00) via credit card only.

Revised 9-2018

Chi Sigma Iota – Chi Upsilon * Student Membership Application

E. APPLICATION Part II (Please type or print clearly)

Name: ______

What interested you in becoming a member of Chi Sigma Iota - Upsilon Chi?

What do you wish to gain from your membership in Chi Sigma Iota - Upsilon Chi?

What qualities (leadership or otherwise) will you bring to Chi Sigma Iota - Upsilon Chi?

______Reminder: Students invited to become members of Chi Sigma Iota - Upsilon Chi Chapter will be requested to fill out an official application and pay membership fees on-line at http://www.csi-net.org/.

PLEASE FILL OUT THE APPLICATION COMPLETELY INORDER TO AVOID ADDITIONAL DELAYS IN THE APPLICATION PROCESS.

Place your completed membership application with attached audit and check inside the RED folder in the CSI mailbox located in Suite ED 322

THANK YOU!!!!!

Revised 9-2018