^{You can print this application, fill it out, and send it to the address on the application. Please make sure you meet the membership requirements.}

PSI CHI
Membership Application

Date:____________________
Semester: Fall______ Spring______ Year______
Full Name:________________________________________________________________
Permanent Address:_________________________________________________________
________________________________________________________________________
Mailing Address:___________________________________________________________
________________________________________________________________________
Day Telephone:______________________Night Telephone:_________________________
CSUN ID#:______________________ Social Security #:___________________________
Total Units Completed:____________________
Total Psychology Units:____________________
Total Units This Semester:__________________
Overall Cumulative G.P.A.:_________________
Psychology G.P.A.:_______________________
Class Standing:__________________________
Estimated Date of Graduation_______________

FOR OFFICE USE ONLY
Recieved:_____/______/______; By:________________________
Reviewed:____/______/_______; By:_______________________
Notified:_____/______/_______; By:________________________
Hours Verified:_______/______/_______; By:_________________
Certificate Mailed:____/______/_______; By:__________________
Payment Type: Check_______ M.O._______ Amt:______________
Over GPA_______ Psych GPA________
Min Units________ Psych Units________
Status:________ Initiation Date:________
Date & Contacted by:_______________________________________
Business Conducted with Initiate:_______________________________

I certify that the information given in this application is true and complete.

_ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ _ _
Applicant's Signature

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