Pledge Report Form

Alpha Chi Sigma – Pledge Report Form

Chapter:

As Chapter Advisor, it is my duty to ensure that all individuals seeking membership with our Fraternity meet all Professional Qualifications before an invitation to membership may be extended (Alpha Chi Sigma Bylaw 1, Section A, Point 2). These Professional Qualifications, found in the Alpha Chi Sigma Constitution Article 1, Section B, Point 2, are as follows:

Students

2. Qualifications for Membership -

a. A candidate for Collegiate membership shall be a student of chemistry who intends to pursue a career in pure or applied chemistry.

c. Reference to chemistry and chemists in connection with membership qualifications shall be interpreted as including chemists, chemical engineers, and members of allied professions in which chemistry predominates.

Faculty/Staff

2. Qualifications for Membership -

b. A candidate for Professional membership shall either have at least a bachelor's degree in chemistry or be a properly qualified chemist.

c. Reference to chemistry and chemists in connection with membership qualifications shall be interpreted as including chemists, chemical engineers, and members of allied professions in which chemistry predominates.

As Chapter Advisor, I certify that the individuals listed on the following pages meet the Professional Qualifications of the Alpha Chi Sigma Fraternity. I further certify that these individuals will meet the Initiation Requirements found in Alpha Chi Sigma Bylaw 1, Section A, Point 9 before being allowed to initiate.

9. No person shall be initiated into the Fraternity until having complied with the following conditions:

1. Be currently enrolled in, or have successfully completed, the second introductory course of the student’s intended course of study.
2. Have successfully received credit for at least one college-level chemistry course.
3. Be without condition in any current college work.

______

Signature/Date

After this page is signed by the Chapter Advisor (either by hand or digitally), this page should be submitted to with the rest of the pledge information.

SAVE THIS AS A WORD DOCUMENT ONLY (NOT PDF)

MAKE SURE TO CHECK RISK MANAGEMENT BOX FOR EVERY PLEDGE

IF PLEDGE HAS PREVIOUSLY BEEN SUBMITTED ON A PRF, CHECK “DEPLEDGED” BOX

ALPHA CHI SIGMA – PLEDGE REPORT FORM

CHAPTER: / INITIATION DATE: / YOUR NAME:
SCHOOL: / TOTAL # OF PLEDGES(includes faculty): / # OF PREVIOUS “DE-PLEDGES” (de-pledge: they have previously been submitted on a PRF and did not initiate)
VALID ADDRESS WHERE MEMBER BADGES SHOULD BE SENT: (if shipping contact is different from “YOUR NAME” please note here)

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.

The pledge previously depledged.

1. (Enter name as it should appear on the membership certificate.)

Select Title: Mr.MissMs.Mrs.Dr. / Name: (first) (middle) (last) Suffix blank, Jr., Sr.IIIIIIVV
Parent address:
City: / State: / Zip:
School address:
City: / State: / Zip:
Date of Birth: / Year in School: / Major: / Minor:
Parent phone: / Cellphone:
Email address:
Professional affiliation(s): ACS AIChE Other:

The pledge has read and understands the Risk Management Policy dated 6/13/2010 and agrees to comply with it in all details. A signed copy has been retained and filed with the chapter.