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    Pi Mu Epsilon Online Membership Enrollment Form
    (Fields denoted * are required.)     		   
      Chapter* School* Street Address* City* St* Zip* Induction Date  
    Chapter Info:  
    example: Michigan Iota Grand Valley State University 1 Campus Drive Allendale MI 49401 3/14/2011  
    Contact Info: Advisor Name * Advisor Email * PFC Name (optional) PFC Email
    (optional)     		Advisor Phone Number *  
       
    example: Paul Fishback fishbacp@mail.gvsu.edu     616-331-2443  
      DATA FOR CERTIFICATES AND JOURNAL SUBSCRIPTION    
      Name exactly as it is to appear on the certificate Permanent address where our Pi Mu Epsilon Journal will find this member for the next year. Member's Email Address  
      FirstName MI. LastName Street Address City St Zip  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Each membership is for one year and costs $20. Enter the number of members enrolled above here: *  
    MERCHANDISE FOR CHAPTERS AND OTHER NEW MEMBERS  
    State any special handling or shipping instructions in the box below. For rush delivery, the street address of your school above and your office phone number are required by our delivery service: Include yourphone numberbelow if you requested rush delivery. No. of KeyPins ($20 each)    
    No. of Honor Cords ($10 each)  
    No. of T-shirts ($10 each)  
    T Shirt Sizes (#S,#M,#L,#XL), e.g., (3,1,4,1)  
    No. PME Constitutions ($1 each)  
    Mathacrostics ($5 each)  
    No. of PME Roll Books ($35 each)  
    No. of PME Banners ($50 each)  
    Total registration and
    merchandise costs     		 
    Rush Delivery via FedEx, $20:  
    Make your check payable to Pi Mu Epsilon, Inc. and send it to: Paul Fishback
    Department of Mathematics, Grand Valley State University, 1 Campus Drive, Allendale, MI 49401         		Grand
    Total     		 
     
    PME's national EIN is 73-6097105. If an invoice for disbursement is required, say yes here:  
       
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