<p> A L P HA P H I A L P HA F RATE R NI TY, I NC . ® | PO BOX 405478, ATLANTA, GA 30384-5478 Life Membership Remittance Form</p><p>IF YOU ARE MAKING A LIFE MEMBER PAYMENT FOR THE FIRST TIME, YOU MUST FIRST COMPLETE THE LIFE MEMBERSHIP APPLICATION AND SEND IT WITH THE PAYMENT!!!</p><p>Member Information Return To:</p><p>Account No. Mail Payment to: Full Name Alpha Phi Alpha Fraternity, Inc. Address P.O. Box 405478 Atlanta, GA 30384-5478 Address 2 City, State Zip For: Contact Number Credit Card Payments Email Address Email: [email protected] Chapter Name</p><p>Payment Date Payment Amount A life membership application must accompany all initial payments!!!</p><p> check box Item Description Total that applies to PLEASE NOTE!!! payment If not fully paid within 5 years, your Initial Payment subscription will be cancelled or rolled over to the current fee. There are no Extended Plan Payment refunds granted to subscribers to the Life Membership Program. Full Payment The Annual Grand Tax payment must be </p><p>F Paid paid in addition to making payments O R</p><p>O towards the Life Membership Plan. The </p><p>F Plan Total F Grand Tax amount paid for the year in I C E</p><p> which the Life Membership Subscription U Balance Due S</p><p>E is completed will be credited to my Life </p><p>O</p><p>N Membership. The National Housing and </p><p>L Exp. Date Y Building Fund assessment of $100 must Plan Completed Life Member No. also be paid if not previously paid.</p><p>Accepted Cards Visa, MasterCard & AMEX Card Type FOR OFFICE USE ONLY Number TRANSACTION DATE: ______Exp. Date PROCESSED BY: ______Name on Card DATE PROCESSED: ______Signature REMITTANCE NO: ______A credit card authorization form is not needed if using this form. </p><p>Phone: 1.800.373.3089 Page 1 of 1 0e3b0debd4289dbbd69804a6b49ff72b.doc Email: [email protected] updated 08/01/2009</p>