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My Contact Information
First Name
*
Last Name
*
Relationship to Referral
*
My Chapter (if applicable)
Home Address
City
State
Zip
Email Address
Cell Phone
Is this a legacy recommendation?
*
Yes
No
Unknown
Referral's Information
First Name
*
Last Name
*
Home Address
City
State
Email Address
Cell Phone
College/University Attending:
*
Relatives in Pi Kappa Alpha
*
What high school
did he attend?
High School Grad Year
Academic record, honors,
and achievements:
High School activities,
including sports:
Hobbies:
Additional Comments: