<p>COUNCIL INFORMATION:</p><p>Check if you would like all correspondence to go to the campus advisor</p><p>Name: Graduate Undergraduate (Example: NPHC of Howard University or NPHC of Dallas) Address: City: State Zip Code: : Tele: Fax: Email: Council Website:</p><p>OFFICER INFORMATION: </p><p>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)</p><p>Chapter should be referenced by Member Organization-Chapter Name (e.g. -Delta Lambda)</p><p>COUNCIL ADVISORS: if applicable</p><p>Campus Tele: h/c w Advisor: Email: </p><p>Alumni Tele: h/c w Council Advisor: Email: </p><p>Qty Item Cost Notes</p><p>Undergraduate Council Dues $150.00</p><p>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</p><p>Replacement Charter $20.00 Note: Charters prior to 1994 may not be available Lapel Pin $15.00 NPHC Badge 1- $10 2-$15</p><p>Total $ Payment Type (check): MO Check Online Remitter: Date:</p>