Revised: 8/25/2021
Name: ___________________________________________ Financial Card Number:_______________
Birthday: _______/______/________
Address: ____________________________________________________________________________
City: _________________________________ State: ________________ Zip: ____________________
Telephone Numbers: Mobile (_____) ________________________
Home (_____) ________________________
Work (_____) ________________________
E-Mail Address: ______________________________________________________________________
FOR REACTIVATIONS ONLY
List all other names previously used: ___________________________________________
___________________________________________
Chapter in which last active: _________________________________________________________
Year in which last active: _________________________________________________________
Chapter in which initiated: _____________________________________________________________
Month/Day/Year Initiated: _________/________/_________
CHECK ALL THAT APPLY
_______ Per Capita…………………………… $125.00
_______ Local Dues………………………….. $245.00
_______ EAF………
………………………….... $ 10.00
_______ First Sisters Outreach (FSO) .….... $ 10.00
_______ Documents………………………….. $ 10.00
(Constitution and Manual of Standard Procedures - Charged only after a Boule)
_______ Housing Fee………………………… $ 25.00
_______ Late
Charges (Chapter)………….. $ 10.00
(If paid after December 31, 2021)
_______ Late Charges (Per Capita )……….. $12.50
(If paid after January 31, 2022)
_______ Reactivating Fee………………….... $ 20.00
_______ Housing Fee………………………… $ 50.00
(New, Reactivating, and Transferring Sorors)
_______ COIP………………………………… $200.00
(Applies to new sorors and reactivating sorors who were last active prior to July 1992)
2022 Remittance Form
Per Capita Tax and Chapter Dues
Alpha Kappa Alpha Sorority, Inc.
Delta Omega Omega Chapter
P.O. Box 2105, Pine Bluff, AR 71613
Total Amount Paid: $_______________ Received By: ___________________________________
Cash: $________Check: $________Check Number: _____________ Other: _________________
Date Received: ____________ PayPal: $_________ Balance:_________ Receipt Number__________
