ALPHA PHI ALPHA FRATERNITY, INC. ® Corporate Headquarters 2313 Saint Paul Street Baltimore, Maryland 21218-5211 www.APA1906.net Phone: 410.554.0040 ● Fax: 410.554.0054
Herman “Skip” Mason, Jr. General President
William Douglass Lyle Executive Director
Brothers, This form is to be completed and submitted to the Regional Vice President or his designee prior to your Chapter being considered for the PRIVILEGE of executing the Initial Membership Development Process (IMDP). Before submitting to the approving individual, please ensure that ALL fields are filled in and the appropriate signatures are received. Much of the data required you should be able to obtain via AlphaNET. However, if there is a discrepancy between the data in AlphaNet and the data entered in this form, please provide proper proof of the data entered when submitting this form. If there are questions about how to fill out this form or what information should be placed in the fields, please contact the Regional Vice-President, his designee or the General Office at forms@apa1906.net. Fraternally, Membership Development Process Team
Founders Henry A. Callis
Charles H. Chapman
Eugene K. Jones
George B. Kelley
Nathaniel A. Murray
Robert H. Ogle
Vertner W. Tandy
ALPHA PHI ALPHA FRAT ERNIT Y, I NC.
®
| 2313 ST. PAUL ST. BALTIMORE, MD 21218
ATTACHMENT A - REQUEST FOR INITIAL MEMBERSHIP DEVELOPMENT
General Information Chapter Name: Chapter Seat: Are all officers IMDP certified
Chapter Tax:
Yes
No
Chapter Key:
% of Chp Brothers IMDP Certified (min 50%)
Give the date the following items were paid or submitted Chapter Insurance: Chapter Directory & Report:
For the following conventions/conferences, give the ratio of Chapter Bros: (registered) vs (delegate strength) Regional Conv: / General/Special Conv: /
GTHGTC*
Give the date(s) you executed the following National Projects/Programs within the past year (*=Mandatory) VPHP* Project:Alpha* Brothers’ Keeper
Is the chapter currently on probation, suspension or have outstanding fees or taxes to the university and or fraternity? If yes, please explain.
Yes No
Are any Brothers in the chapter on probation or suspended by the college/university or fraternity? If yes, provide name(s), and date(s):
Yes
Does your chapter have unpaid fines as a result of a fine(s) of a brother(s)? If yes, please explain.
Yes
No
No
College Chapters Only: Chapter GPA (cumulative)
/4.0
Alpha Advisor’s Name Alpha Advisor’s Chapter
Alpha Advisor Information Date Alpha Advisor Certified Date IMDP Certified
Alumni Chapters Only: Does Your Chapter have a Reclamation/Retention Plan? If so, describe it. If not, explain why?
Total number of active Brothers in your Chapter How many Brothers initiated within the past 3 Fraternal years
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How many Brothers have been reclaimed within the past Fraternal year How many Brothers initiated within the past 3 Fraternal years are ACTIVE
Yes
Reclamation % Increase Retention %
No
Revision 2011-12-07
Chapter IMDP Team Please list the chapter members participating in IMDP, their cumulative GPA (on a 4.0 equivalent scale – College Only) and the dates they were certified in Risk Management (RM), Initial Membership Development Program (IMDP). Also, if they are certified to sponsor candidates please list the date they completed Sponsor Certification (SC). Office
Acct #
Name
GPA/4.0
President
VP
Secretary
Treasurer Dean of Membership
Dates the following certifications achieved
RM
IMDP
SC
Dir. of Educ. Act. Assoc Editor to the Sphinx
Historian
Chaplain
Sgt. At Arms
Parliamentarian
Members:
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Revision 2011-12-07
Request for Dates and College / University Authorization TO BE FILLED OUT BY CHAPTER/CLUSTER TEAM Name of Campus Advisor
College / University(s) participating
Event: Alpha Awareness Smoker Sphinxman Meeting
Cluster Weekend
1 2 3 4 1 2 3 4
Date(s)
Location(s)
Time(s)
The chapter hereby certifies that the above information is correct and will comply with the rules and regulations of the above college / university(s) and Alpha Phi Alpha Fraternity. We, further acknowledge that the chapter understands that failure to comply with the rules and regulations of the college / university(s) and Alpha Phi Alpha may result in disciplinary actions, including fines, expulsion, suspension and prosecution of chapter members and de-chartering of the chapter. Position Print Name Signature Date President
Secretary
Dean of Membership Development
TO BE FILLED OUT BY THE COLLEGE/UNIVERSITY College/ University window for membership
I, hereby authorize the above mention chapter to conduct membership development within current rules and regulations of the below stated college / university(s) and Alpha Phi Alpha Fraternity, Inc. College / Univ. Position Print Name Signature Date
TO BE FILLED OUT BY THE FRATERNITY LEADERSHIP Attest: Chapter Advisor:
Regional Vice President Approval (or designee)
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Revision 2011-12-07