Pi Mu Epsilon Online Membership Enrollment Form

Part 1. Contact Information

Chapter and State, e.g. Michigan, Iota:
Institution
Advisor's First Name:
Advisor's Last Name:
Advisor's Email Address:
Address (where certificates and merchandise will be sent)
Address 2
State, Zipcode
Primary Faculty Correspondent's (PFC) First Name (if different from advisor):
PFC's Last Name:
PFC Email Address:

Part 2. Inductee Information

Note: The permanent address is where the Pi Mu Epsilon Journal will be mailed during the next year. Names will appear on membership certificates exactly as they are entered below.

	First Name and M.I..	LastName	Address	City	State	Zip	EmailAddress
1
2
3
4

Note: If your chapter is inducting more than 30 students, please complete a second copy of this form.

Part 3. Merchandise and Fees

Number of Enrollees Listed Above
Number of Keypins ($20 each)
Number of honor cords ($10 each)
Number of t-shirts ($10 each)	Extra Large: Large: Medium: Small:
Number of PME rollbooks ($35 each)
Number of PME banners ($50 each)
Number of PME Constitutions ($2 each)
Number of Mathacrostics ($5 each)
Rush Delivery: Yes ($20) No
TOTAL FEES DUE:

Make your check for the TOTAL FEES DUE payable to Pi Mu Epsilon, Inc. and send it to:

Paul Fishback
Pi Mu Epsilon Society
Department of Mathematics
Grand Valley State University
1 Campus Drive
Allendale, MI 49401

If a you do not receive confirmation of your chapter order within 5 days, please email Professor Angela Spalsbury at membership@pme-math.org

If, after hitting the Submit key, you do not see a verification,please notify the PME Webmaster.