KAPPA ALPHA PSI FRATERNITY, INC.® PROVINCE ...

KAPPA ALPHA PSI FRATERNITY, INC. ®
______________________________ PROVINCE
MEMBERSHIP INTAKE – ALUMNI
BALANCE SHEET
(Please complete and submit only one form per chapter)
This Balance Sheet is effective for membership intake(s)
prior to or at the _________________________________
PLEASE SEND A SEPARATE CHECK/MONEY ORDER FOR EACH ITEM (i.e., a money order or certified check
for the total Grand Chapter Membership Intake Fees, and a chapter check money order, or certified check for the
Province Fees). This document, along with all forms/items identified on Form 63 (Alumni Candidate Checklist),
must be received by the date indicated below).
1. Grand Chapter Membership Intake Fees
#1 ($785) #2 ($841) #3 ($858) Quantity* Total
Alumni Badge: X = $
*The quantity total MUST match the number of initiates. Unless otherwise instructed, payment is due by money
order or certified check payable to Kappa Alpha Psi –_________________________ Province. No
personal or chapter checks will be accepted for Grand Chapter Fees. One combined Province issued
check may be issued to IHQ for all Grand Chapter membership intake fees.
2. ________________________________ Province Fees
Number of Initiates: X $ = $
(total from below)
The ________________________ Province Fees include:
• C. Rodger Wilson Leadership Conference $
• Province Meeting Registration $
• Province Dues $
• Province Chapter Administration Fee $
• Orientation Meals $
• Undergraduate Luncheon $
• Kappa Foundation Luncheon $
Payment is due by chapter check, money order or certified check payable to Kappa Alpha Psi –
______________________________ Province. No personal checks will be accepted.
NOTE: Province MOIP Coordinator __________________________________must receive
membership intake forms and fees by _______________________________________.
Chapter Name:
Polemarch: Phone #:
Keeper of Records: Phone #:
MOIP Coordinator: Phone #:
MOIP Province Balance Sheet_Alumni_063012.doc FY 2012-2013

KAPPA ALPHA PSI FRATERNITY, INC. ®
______________________________ PROVINCE
MEMBERSHIP INTAKE – ALUMNI
BALANCE SHEET
(Please complete and submit only one form per chapter)
MOIP Province Balance Sheet_Alumni_063012.doc FY 2012-2013