11N-Legacy Application Certification Form 2 | P a g e
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Part D - Affirmation Statement:
Instructions: This section must be signed in the presence of a Notary Public.
DATED: _______________________
_____________________________________________________________________ _____________
Signature of Member or Member Advocate Date
Printed Name of Member or Member Advocate Member Number
Member or Member Advocate Chapter Affiliation Region
Member or Member Advocate Email Address and Phone Number
STATE OF )
) ss.
COUNTY/PARISH OF )
On ________________, 202_, before me, __________________________, a Notary Public in and for the jurisdiction
aforesaid, personally appeared _______________________, who proved to me on the basis of satisfactory evidence to be the
person whose name is subscribed to the within instrument and that that person ackowledged to me that she executed the same in
her individual/and or authorized capacity, and that by her signature on the instrument that person, or the entity upon behalf of
which the person acted, executed the instrument intending to be legally bound.
I affirm and certify under the penalty of perjury under laws of the jurisdiction where this instrument is executed, that the
information provided in this application is true, complete, and correct. Additionally, I understand that whether or not perjury is
determined, that falsification of any information on this application (or providing incomplete or incorrect information) could
result in the signatory being subject to disciplinary action up to and including permanent expulsion from membership in Delta
Sigma Theta Sorority, Incorporated. For a non-member person, that person may be permanently barred from membership in
Delta Sigma Theta Sorority, Incorporated.
WITNESS my hand and official seal.
Signature_____________________________ (Seal)
My Commission Expires:
*This form must be completed in its entirety and uploaded with the membership application of the Legacy Applicant.
The Legacy Applicant must meet all the qualifications required for membership and receive the vote of the chapter and
approval by the Regional Director.
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