FIMRC: Chapter Personal Information Form

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FIMRC : Chapter Personal Information Form

Please complete and then print this page and mail to:

FIMRC
P.O. Box 1132
Philadelphia, PA 19105-1132

or

Fill out completely and submit.

	NAME:

	(Last)	(M.I.)	(First)

	CURRENT ADDRESS:
Street:

City:
State:
Zip:

	PERMANENT ADDRESS:
Street:

City:
State:
Zip:

	PHONE:
Current:
Mobile:
Fax:
Permanent:
eMail:

Currently Enrolled in:	High School
	College or University	Major:
	Graduate Studies	Field:

Name of School:

Year in School:	Freshman Sophomore Junior Senior Other:

Degree Program:	Please specify if Other:

Expected Date of Graduation:
Expected Career:

Chapter Board Position: (if applicable)

Additional Comments: