Alpha Theta State
U.S. Forum
Stipend Application

Process:

1. Applicants mail completed application to Professional Affairs Chairman (Due February 13, 2004)
2. The State Professional Affairs Committee identifies two finalists and two alternates by February 20.
3. Finalists are notified by February 23, allowing them to make timely travel arrangements. Alternates, if needed, are notified at that time.
4. A stipend is provided to assist representatives with transportation, registration, and hotel expenses. The stipend will be given to the selected representatives prior to the Forum.

         Last                  First
   Name:                 

  Home Phone:  -
  Work Phone:  -

         Street                     City             State  Zip
Address:       

            Chapter          
Member of:  
       Alpha
       Beta
       Gamma
       Zeta
       Theta
       Iota
       Kappa
       Lambda
       Mu
       Nu
       Xi
       Omicron
       Pi
       Rho
       Sigma
       Chi
       Psi
       Omega
       Alpha Alpha
       Alpha Beta
       Alpha Gamma
  Number of Years: 

Society Positions: (Participation, Offices Held)
Chapter:   
           
           
           

State:     
           
           

Number of Years in Education:  

Present Professional Position and Location:
           
           
           

Past Positions in Education or Community That Would Relate to U.S. Forum Activities:
           
           
           
           
           

Reasons for applying for U.S. Forum stipend:
           
           
           
           
             

What would make you a good representative for Utah members of Delta Kappa Gamma?
           
           
           
           
           

Would you be willing to share U.S. Forum information with chapters?  Yes  No 
Describe how:
           
           
           

Instructions for Submission
Fill in form, print it out on your computer, and send via US Mail to:

Andrea Bagnell
2003-2005 Professional Affairs Chairman
1381 Winder Lane
Salt Lake City, UT  84124