1 Chi Sigma Iota - Upsilon Chi * Student Membership 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 certificate: _________________________A. APPLICATION _________________________________________ Name, as you would like it to appear on Membership Certificate: Mailing address: ___________________________________________________________________________ Name: _________________________________________Mailing Address: _________________________ Name: ______________________________________________________________________ Street: _________________________________________Street: _______________________________________________________________________________________________ City: ________________________________________ City: _________________________________________ _________________________ 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: __________________________________________________________ City: _________________________________________ _________________________ 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 Universities you attended: ____________________ __________________________________ Counselor Education degree work completed (credit hours): ________________________ GPA: _________ (min. 3.5 on 4.0 system) Expected date of graduation: ________________________________________________ Program/Track: ___________________________________ _________________________ 2 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 3 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 .