Graduate MIP Manual (January 2021)
Section II Request for Authorization to Conduct Graduate MIP Form
Graduate Chapter Name____________________________________ Region _______________________________
Chapter Address _____________________________________________________
City/State/Zip Code_______________________________________________________________________________
Chapter Orientation Workshop Date(s): 1: _____________________ 2: _____________________ 3: _______________
In
formation Session Date: _____________________________
MI
P Session Date Week 1: ____________________________
MI
P Session Date Week 2: ____________________________
MI
P Session Date Week 3: ____________________________
Chapter Basileus___________________________________ _________________________________________
Print Name Signature
Bas
ileus Phone No. _________________________________ Email ____________________________________
Mem
bership Chairman_________________________________ _________________________________________
Print Name Signature
Membership Chairman Phone No._____________________________ Email ____________________________________
El
ectronic submission date: _____________________
OFFICIAL USE – REGIONAL DIRECTOR
Date Received_________________________ Date of Last MIP:____________________ Retention Rate: _______________
Health Check Verified Yes No
Schedule of MIP Activities Yes No
Sponsor Criteria Approved Yes No
Files Current Yes No
List of Eligible Sponsors/Co-sponsors Yes No
Co
mment(s):_________________________________________________________________________________________________
____
________________________________________________________________________________________________________
Request for MIP Approved Denied
____
_____________________________________ _________________
Regional Director’s Signature Date
OFFICIAL USE – REGIONAL DIRECTOR
No Signature Needed - Electronically Submitted
No Signature Needed -
Electronically Submitted
click to sign
signature
click to edit
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