Prospective Charter Application
University/College: ______
Date of Application: ______
Address: ______
______
Website: ______
University Contact/Advisor: (name)______
(title & department) ______
(mailing address)
(phone) ______(e-mail) ______
University co-Advisor: (name) ______
(title & department) ______
(mailing address)
(phone) ______(e-mail) ______
List the name and contact information for additional administrator(s) and/or faculty member(s) who support the chartering of the Society:
1.______
______
2. ______
______
Institutional Information (Please circle/highlight…)
Type of Institution: Public/Private ¿ Setting: Urban/Suburban/Rural ¿ Calendar: Semester/Quarter
Degrees offered (circle all that apply): bachelor’s/master’s/doctorate
Current institutional accreditations: ______
______
Student Information
Head count enrollment for entire institution:
1. Undergraduate: FT______/ PT______2. Graduate: FT ______/ PT______
Mission Alignment
Please describe why you believe that the Mission of Golden Key (to enable members to realize their potential through the advancement of academics, leadership and service) is congruent with the Mission of your College/University? ______
Please provide a brief list of campus offices and/or student groups that you can see Golden Key collaborating with: ______
Why do you believe Golden Key would be an impactful organization to integrate into your campus community? ______
Please type your initials on the spaces below confirming that you agree to the following:
The institution will provide the Society, on an annual basis, with a list of prospective members, including:
______Top 15% of sophomores, juniors and seniors
______Top 15% of graduate students
The institution will work collaboratively with Golden Key to determine the BEST time of the academic year to acquire this list of prospective/eligible member. (Typically, first 2-3 weeks of the class start date)
The institution agrees to provide the prospective student list including the following information in an excel document:
Field 1: Eligible Student’s Last Name
Field 2: First Name
Field 3: E-mail Address
Field 4: Middle Name
Field 5: Major field of study
Field 6: Class/Year in College (i.e. junior, senior)
Field 7: Campus (local) Address
Field 8: City
Field 9: State
Field 10: Zip Code
Field 11: Campus/Local Phone Number
Field 12: Permanent (home) Address
Field 13: City
Field 14: State
Field 15: Zip Code
A list of eligible members will be provided in an alternative format. Please provide detailed explanation:
Please send this form and any other support information to:
Lenora Oeters
Associate Director, U.S. University Relations
Golden Key International Honour Society
1040 Crown Pointe Parkway, Suite 900
Atlanta, GA 30338
Voice: 678.689.2210 • Fax: 678.689.2298
www.goldenkey.org
MAR 12