Alpha Epsilon Delta
The Health Preprofessional Honor Society
MEMBERSHIP RECORD FORM*** (MRF)
For National Office Use Only
MEMBERSHIP NUMBERS
National ______________________
Chapter __________________
Available on our website: “Member Resources”/ “Forms & Documents”
To insure prompt processing, please make sure form is complete and correct; incomplete or incorrect forms will
not be processed for membership. Reproduce form as necessary. PLEASE TYPE on line and print.
Mr.
Ms.
Mrs.
Dr.
Prof.
Other
FULL NAME (for certificate printing)
_________________________________
First
________________________
Middle
_____________________________________
Last , Suffix & Degree (if applicable)
GENDER
BIRTH DATE
______/_____/________
Month Day Year
__________________________________________
AED Chapter (State & Greek Letter – not symbol)
Male Female
____________________________________________________________________________________
College/University or Other Affiliation for Honorary memberships
For National Office Use Only
Chapter # ___________
Type of
Membership
(Choose one)
Student ($75) – A student who is currently enrolled in a health preprofessional curriculum and has fulfilled
requirements (including Chapter’s) for AED membership Article II, Section 2.
Honorary ($50) – An individual whom your chapter has chosen to honor for their services & contributions to AED
and health preprofessional education –– advisor/s, educational and/or professional practitioners
please do not release my information for promotional items directly related to AED
PRESENT (SCHOOL) ADDRESS:
____________________________________________ ______________________________ _______ ___________
Street/P.O. Box City State Zip
Phone (_____)_______________ E-mail _______________________________________________
PARENT’s PERMANENT ADDRESS:
___________________________________________________________________________
Parent (s) Name
____________________________________________ _____________________________ ________ ___________
Street/P.O. Box City State Zip
Phone (_____)_______________ E-mail ________________________________________________________
CLASS * Required for Student Membership*
2 3 4 4+
Soph. Jr. Senior Senior +
ANTICIPATED DATE OF GRADUATION
___________/______/____________
Month Day (approx) Year
INITIATION DATE – Celebration
* Required for all memberships *
___________/_______/____________
Month Day Year
CANDIDATE STATEMENT: I hereby acknowledge an invitation to become a National Member of Alpha Epsilon Delta. I have
fulfilled all membership requirements. It is my intent to improve the Society by investing my energy, enthusiasm, and commitment.
By signing this form I am authorizing the release of my GPA information to the AED National Office and my Chapter Advisor.
* both GPAs are Required (below) for Student Membership*
CHAPTER VERIFICATION: Candidate’s (Signature) Date
The above named candidate has been enrolled in an institution of higher education for a minimum of three semesters or
five quarters and has attained a ________ science (BCPM) GPA AND a ________ overall GPA (based on a 4.00 scale).
_____________________________________ ________________________________________
Chapter Advisor (Signature) Chapter Secretary (Signature)
*** AED Chapter – send all original MRFs for each Initiation Date & one check covering fees to:
AED National Office and retain a copy for your records. No refunds – credit only policy.
AED National Office • James Madison University • MSC 9015 • 601 University Blvd • Harrisonburg, VA 22807
Telephone: 540/568-2594 • Fax: 540/568-2595 • E-mail: aed@jmu.edu
dhf 1/13/2009 Website: http://www.nationalaed.org/
