Omicron Delta Kappa Membership Form

Please complete the following form , print it out and submit it to Please return the completed application to the Campus Center Main office of to Dr. Lipuma’s Office—Culimore room 420. For more information please contact Dr. Jim Lipuma at 973-642-4743 or lipuma@njit.edu

All fields marked with * are required.

*College/University:

Cum. GPA:   Grading System:

*Name
	(Last)	(First)	(Middle)

Name (as desired on certificate if different from above):

 (No nicknames)

*Major Area(s) of Study:

*Permanent Address:	Street/Apt. No.
	City	State	Zip

Phone: ( ) -

Permanent E-mail Address:

*Class Standing: Choose One Junior Senior Grad Student Fac/Staff Alumni Honoris Causa

*If Alumni, Year Graduated:

Other College/University Attended, Yrs. and Degrees:

*Initiation Date:

/

/

Social Security No.

-

-

Month/Day/Yr.

*Gender:

Choose One Male Female

Birth Date:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991

 Month/Day/Yr.

I certify member’s eligibility and initiation date. yes no

Initiation Fee: paid unpaid	__________________________________________________________________
	Faculty Secretary Signature

LIST YOUR SIGNIFICANT HONORS UNDER APPROPRIATE HEADINGS BELOW:

I. SCHOLARSHIP:

II. ATHLETICS: 

III. CAMPUS OR COMMUNITY SERVICE, SOCIAL (NAME OF SORORITY OR FRATERNITY),
RELIGIOUS ACTIVITIES AND CAMPUS GOVERNMENT: 

IV. JOURNALISM, PUBLICATIONS, SPEECH, AND THE MASS MEDIA: 

V. CREATIVE AND PERFORMING ARTS: