STUDENT MEMBERSHIP INTENT FORM
Sigma Theta Tau Pi Chapter (015)
Congratulations on your recent invitation to join Sigma Theta Tau Pi Chapter!
Please complete this Membership Intent Form and return it to:
Baltimore Campus: Dr. Megan Lynn
Shady Grove Campus: Ms. MaryPat Ulicny
Please indicate if you are a:
_____Undergraduate Student
_____Graduate Student
Name: (please present clearly as this will be used for your certificate)
Present Address:
City, State, Zip:
Permanent Address:
City, State, Zip:
Phone:
Permanent email address: (confirmation of membership will be made through this email
address)
Expected graduation semester/year:
Under the provisions of the “Family Education Rights and Privacy Act of 1974”, I grant access to my academic record to the Chapter Eligibility
Committee chairperson for consideration of my membership to Sigma Theta Tau International. I undeerstand this invitation may be revoked
between now and induction or thereafter if I am found guilty of a breach in academic integrity or other behaviors/actions inconsistent with the
principles of the society. My signature implies consent to forward my name to Sigma Theta Tau Int’l for consideration of membership –(Pi
Chapter).
Student’s Signature / Date: