Yes		No
_____		_____		I am currently enrolled at Lane in an Associate Degree, Certificate, or other program approved for transfer to a 4-year institution.
_____		_____		I have successfully completed 12 full-time credits or 18 part-time credits.
_____		_____		I have an accumulative grade point average of 3.25 or higher.
_____		_____		Two faculty will sign to witness my self-motivation and dedication to excellence.
_____		_____		I understand that I must meet the standards outlined above and pay one-time only local, Oregon Region, and International dues.*

*Pay dues of $80 and participate in Chapter activities of my choice with no requirements to attend any activities. (Members transferring from another Phi Theta Kappa Chapter pay $30; contact the advisor for this process.) Membership dues will only be accepted by adding a CRN for the fee through MyLane. Please see our web site (2011sitearchive.lanecc.edu/ptk) for the current CRN number.) We will go online to verify that you paid.

If you answered Yes to all of the questions above, please clearly complete the following:

Name:	___________________________________________
L Number:	______________________
Address:	___________________________________________
City, Zip	___________________________________________
Phone:	___________________________________________
E-mail:	___________________________________________
Major:	__________________________________________
Graduation Term & Year:	___________________________________________		______________________    (or transfer)

Please assist us with your membership by checking one of the following:

_____		Please call me! I would like to be involved in chapter activities.
_____		Please e-mail me about activities. I'll participate if I can.

	____________________________________		________________
	Applicant's Signature		Date

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Please let us know how you learned about Phi Theta Kappa by checking the following:

_____	College Catalog		_____	The Torch		_____	PTK Members or Officers
_____	PTK Orientation		_____	PTK Advisor		Other:	______________________

I recommend this student for membership in Phi Theta Kappa.

	____________________________		__________		____________________________		__________
	Faculty signature		Lane Ext.		Faculty signature		Lane Ext.

To finish this application, complete the following FOUR steps:

_____		1.		Complete all blanks on this form.
_____		2.		Review your current transcript to make sure you meet the requirements.
_____		3.		Add the CRN and pay for Phi Theta Kappa Membership (see * above).
_____		4.		Submit all paperwork to:
				Ce Rosenow, PTK Sigma Zeta Advisor
				Mail to: Lane Community College, 4000 East 30th Ave
				Eugene, OR 97405
				Deliver to: Building #17, Room 312

Membership cannot be processed until you have:

_____

Completed Application

_____

Reviewed Transcript

_____

CRN & Dues

Phi Theta Kappa is very active at Lane CC and throughout the community. By completing this application, you authorize Phi Theta Kappa to use your likeness while participating in activities, without charge, for promotional purposes. These purposes may include Web site, posters, and print, audio, and video media.

Please click here for a printable PDF.